# 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:** 1962582023
- **Authorized official:** LEEA JEANINE WALTON (RCS MANAGER)
- **Authorized official phone:** (704) 316-6081

## Contact information

- **Practice address:** 7752 GATEWAY LN NW, SUITE 100, CONCORD, NC 28027-4421
- **Practice address phone:** (704) 316-4950
- **Practice address fax:** (704) 316-4951
- **Mailing address:** PO BOX 60447, CHARLOTTE, NC 28260-0447
- **Mailing address phone:** (704) 316-4950
- **Mailing address fax:** (704) 316-4951

## 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:** 10/16/2006
- **Last updated:** 07/09/2024

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 018TT | BCBS-NC | NC |
| 05 | — | 5905550 | — | NC |
| 05 | — | GPB795 | — | SC |