# NOVANT HEALTH MEDICAL GROUP, LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Other names:** Novant Health Waverly Pediatrics and Primary Care
- **Organization subpart:** No

## Provider details

- **NPI number:** 1871527762
- **Authorized official:** LEEA JEANINE WALTON (RCS MANAGER)
- **Authorized official phone:** (704) 316-6081

## Contact information

- **Practice address:** 11840 SOUTHMORE DR, SUITE 200, CHARLOTTE, NC 28277-4466
- **Practice address phone:** (704) 384-1166
- **Practice address fax:** (704) 384-1181
- **Mailing address:** PO BOX 60447, CHARLOTTE, NC 28260-0447
- **Mailing address phone:** (704) 384-1166
- **Mailing address fax:** (704) 384-1181

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NC | Yes |
| 207R00000X | Internal Medicine Physician | — | NC | — |
| 208000000X | Pediatrics Physician | — | NC | — |

## Other

- **Enumeration date:** 07/10/2006
- **Last updated:** 06/21/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 016XU | BCBS-NC | NC |
| 05 | — | 5901214 | — | NC |
| 01 | — | CC5118 | RAILROAD MEDICARE | NC |
| 05 | — | NPB256 | — | SC |