# NOVANT HEALTH MEDICAL GROUP, LLC

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

## Provider details

- **NPI number:** 1770511313
- **Authorized official:** LEEA JEANINE WALTON (RCS MANAGER)
- **Authorized official phone:** (704) 316-6081

## Contact information

- **Practice address:** 6324 FAIRVIEW ROAD, SUITE 201, CHARLOTTE, NC 28210-4278
- **Practice address phone:** (704) 384-0588
- **Practice address fax:** (704) 384-0580
- **Mailing address:** PO BOX 60447, CHARLOTTE, NC 28260-0447
- **Mailing address phone:** (704) 384-0588
- **Mailing address fax:** (704) 384-0580

## Taxonomy

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

## Other

- **Enumeration date:** 06/30/2006
- **Last updated:** 07/09/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 017X3 | BCBS NC | NC |
| 05 | — | 5903451 | — | NC |
| 01 | — | CC5118 | RAILROAD MEDICARE | NC |
| 05 | — | NPB165 | — | SC |