# NOVANT HEALTH MEDICAL GROUP, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Novant Health Lakeside Primary Care
- **Organization subpart:** No

## Provider details

- **NPI number:** 1063771749
- **Authorized official:** LEEA JEANINE WALTON (RCS MANAGER)
- **Authorized official phone:** (704) 316-6081

## Contact information

- **Practice address:** 13460 PLAZA ROAD EXT STE 100, CHARLOTTE, NC 28215-8923
- **Practice address phone:** (704) 316-4990
- **Practice address fax:** (704) 316-4998
- **Mailing address:** PO BOX 60447, CHARLOTTE, NC 28260-0447
- **Mailing address phone:** (704) 384-7603
- **Mailing address fax:** (704) 417-4479

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 05/15/2012
- **Last updated:** 07/09/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 5921588 | — | NC |