Healthcare Provider Details

I. General information

NPI: 1639179393
Provider Name (Legal Business Name): NOVANT HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MOCKSVILLE AVE FL 2
SALISBURY NC
28144-2735
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-633-9620
  • Fax: 704-633-7504
Mailing address:
  • Phone: 704-633-9620
  • Fax: 704-633-7504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LEEA JEANINE WALTON
Title or Position: RCS MANAGER
Credential:
Phone: 704-316-6081