NPIMap

Organization Active NPI

Novant Health Medical Group, LLC

Doing business as Novant Health Lakeside Primary Care

  • Family Medicine Physician
  • Concord, NC
National Provider Identifier
1093976474
Registry record updated Jul 9, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
NOVANT HEALTH MEDICAL GROUP, LLC
Doing business as
Novant Health Lakeside Primary Care
Practice address
5325 Vinning St NW
Suite 101
Concord, NC 28027-2956
Phone
(704) 316-1040
Fax
(704) 316-1041
NPI assigned
Jun 19, 2008
Last updated
Jul 9, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Leea Jeanine Walton
Title
RCS Manager
Phone
(704) 316-6081

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X NC Primary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X NC

Addresses

Primary practice location

5325 Vinning St NW
Suite 101
Concord, NC 28027-2956

Mailing address

PO Box 60447
Charlotte, NC 28260-0447
Phone (704) 316-1040

Other names 1

  • Novant Health Lakeside Primary Care Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060828000304 NC Part B Supplier - Clinic/Group Practice 1153234893 Receives reassigned benefits from 106 practitioners
19 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Salisbury, NC; Matthews, NC; Locust, NC; Durham, NC; Concord, NC; Charlotte, NC

Other NPIs on the same Medicare enrollment 19

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 19

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1213833600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1720483200000",
    "number": "1093976474",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 60447",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282600447",
            "telephone_number": "704-316-1040",
            "fax_number": "704-316-1041"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5325 VINNING ST NW",
            "address_2": "SUITE 101",
            "city": "CONCORD",
            "state": "NC",
            "postal_code": "280272956",
            "telephone_number": "704-316-1040",
            "fax_number": "704-316-1041"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NOVANT HEALTH MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-06-19",
        "last_updated": "2024-07-09",
        "certification_date": "2024-07-09",
        "status": "A",
        "authorized_official_last_name": "WALTON",
        "authorized_official_first_name": "LEEA",
        "authorized_official_middle_name": "JEANINE",
        "authorized_official_title_or_position": "RCS MANAGER",
        "authorized_official_telephone_number": "704-316-6081"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "NC",
            "license": null,
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "NC",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Novant Health Lakeside Primary Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Novant Health Lakeside Primary Care",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Concord, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.