Organization
NOVANT HEALTH MEDICAL GROUP, LLC
Active
Other names
Novant Health Lakeside Primary Care
Organization subpart
No
Provider details
NPI number
Authorized official
LEEA JEANINE WALTON (RCS MANAGER)
(704) 316-6081
Entity
Organization
Contact information
Practice address
7752 GATEWAY LN NW, SUITE 100, CONCORD, NC 28027-4421
(704) 316-4950
(704) 316-4951
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(704) 316-4950
(704) 316-4951
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
NC
207R00000X
Internal Medicine Physician
—
NC
208000000X
Pediatrics Physician
—
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
018TT
BCBS-NC
NC
05
—
5905550
—
NC
05
—
GPB795
—
SC
Enumeration date
10/16/2006
Last updated
07/09/2024
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