Organization
NOVANT HEALTH MEDICAL GROUP, LLC
Active
Other names
Novant Health Waxhaw Family & Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
LEEA JEANINE WALTON (RCS MANAGER)
(704) 316-6081
Entity
Organization
Contact information
Practice address
3614 PROVIDENCE RD S, SUITE 100, WAXHAW, NC 28173-6309
(704) 384-8640
(704) 384-8650
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(704) 384-8640
(704) 384-8650
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0276T
BCBS
NC
05
—
890276T
—
NC
01
—
CC5118
RAILROAD MEDICARE
NC
05
—
NPA885
—
SC
Enumeration date
06/02/2006
Last updated
07/09/2024
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