=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235458985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVANT HEALTH MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2010
-----------------------------------------------------
Last Update Date | 07/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10500 LIGON MILL RD SUITE 113
-----------------------------------------------------
City | WAKE FOREST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27587-4576
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-570-5705
-----------------------------------------------------
Fax | 919-570-5710
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 60447
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-0447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-570-5705
-----------------------------------------------------
Fax | 919-570-5710
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RCS MANAGER
-----------------------------------------------------
Name | LEEA JEANINE WALTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-316-6081
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2005-01578
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------