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	208200000X	Plastic Surgery Physician

General Provider Information

NPI Number	:	1538578174
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	:	704-384-7606
Fax Number	:

Provider Business Practice Location Address
First Line	:	1456 N HOWE ST STE 201
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-2674
Country	:	US
Telephone Number	:	910-754-8808
Fax Number	:

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

Provider Enumeration Date	:	08/07/2014
Last Update Date	:	03/26/2025

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