MEDICARE: NOVANT HEALTH MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1477113462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVANT HEALTH MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:	704-384-7840
Fax Number	:

Provider Business Practice Location Address
First Line	:	416 EAST 36TH STREET
Second Line	:	SUITE 200
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-1030
Country	:	US
Telephone Number	:	980-302-9800
Fax Number	:	980-302-9810

Authorized Official
Title or Position	:	RCS MANAGER
Name	:	LEEA JEANINE WALTON
Credential	:
Telephone Number	:	704-316-6081

Provider Enumeration Date	:	06/20/2019
Last Update Date	:	07/09/2024

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