# NOVANT HEALTH MEDICAL GROUP, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Novant Health Lakeside Family Physicians
- **Organization subpart:** No

## Provider details

- **NPI number:** 1356394308
- **Authorized official:** LEEA JEANINE WALTON (RCS MANAGER)
- **Authorized official phone:** (704) 316-6081

## Contact information

- **Practice address:** 19485 OLD JETTON RD STE 100, CORNELIUS, NC 28031-6583
- **Practice address phone:** (704) 384-1775
- **Practice address fax:** (704) 384-1776
- **Mailing address:** PO BOX 60447, CHARLOTTE, NC 28260-0447
- **Mailing address phone:** (704) 384-1775
- **Mailing address fax:** (704) 384-1776

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 207QS0010X | Sports Medicine (Family Medicine) Physician | — | NC | — |
| 225100000X | Physical Therapist | — | NULL | — |
| 225100000X | Physical Therapist | — | — | — |

## Other

- **Enumeration date:** 05/19/2006
- **Last updated:** 03/30/2026

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0215V | BCBS-NC | NC |
| 05 | — | 5903870 | — | NC |