Healthcare Provider Details

I. General information

NPI: 1215326665
Provider Name (Legal Business Name): NOVANT HEALTH MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1456 N HOWE ST STE 201
SOUTHPORT NC
28461-2674
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 910-721-4000
  • Fax: 910-721-4001
Mailing address:
  • Phone: 910-721-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

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