Provider Demographics
NPI:1104152024
Name:NOVANT MEDICAL GROUP INC
Entity type:Organization
Organization Name:NOVANT MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:RCS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEEA
Authorized Official - Middle Name:JEANINE
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-316-6081
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-279-1679
Mailing Address - Fax:704-279-1677
Practice Address - Street 1:111 S SALISBURY GQ AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28146-8150
Practice Address - Country:US
Practice Address - Phone:704-279-1679
Practice Address - Fax:704-279-1677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOVANT MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-28
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208000000X
207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913612Medicaid
NC2343183FMedicare PIN