Novant Medical Group Inc – Family Medicine Physician

Key facts

NPI: 1104152024
Entity type: Organization (NPI type 2)
Primary specialty: Family Medicine Physician 207Q00000X
Legal business name: NOVANT MEDICAL GROUP INC
Practice address: 111 S Salisbury GQ Ave
Salisbury, NC 28146-8150
Phone: (704) 279-1679
Fax: (704) 279-1677
NPI assigned: Oct 28, 2009
Organization subpart: Yes
Parent organization (as reported): NOVANT MEDICAL GROUP, INC

Authorized official

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

Medicare participation

Medicare fee-for-service enrollment: Enrolled in NC

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
O20031121000692	NC	Part B Supplier - Clinic/Group Practice	1153234893	Receives reassigned benefits from 3,607 practitioners This NPI is an additional NPI on the enrollment

National Provider Directory

Part of: Presbyterian Inpt Care

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Family Medicine Physician Group: 193200000X MULTI-SPECIALTY GROUP	207Q00000X			Yes
Pediatrics Physician Group: 193200000X MULTI-SPECIALTY GROUP	208000000X		NC

Addresses

Primary practice location

111 S Salisbury GQ Ave
Salisbury, NC 28146-8150

Mailing address

PO Box 60447
Charlotte, NC 28260-0447
Phone (704) 279-1679

Other identifiers

Identifier	Type	State	Issuer
5913612	Medicaid	NC

Other names

Novant Health Granite Quarry Internal Medicine & Pediatrics Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jul 10, 2023.

{
    "created_epoch": "1256688000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1688947200000",
    "number": "1104152024",
    "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": "704-279-1679",
            "fax_number": "704-279-1677"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 S SALISBURY GQ AVE",
            "city": "SALISBURY",
            "state": "NC",
            "postal_code": "281468150",
            "telephone_number": "704-279-1679",
            "fax_number": "704-279-1677"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NOVANT MEDICAL GROUP INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NOVANT MEDICAL GROUP, INC",
        "enumeration_date": "2009-10-28",
        "last_updated": "2023-07-10",
        "certification_date": "2023-07-10",
        "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": null,
            "license": null,
            "primary": true
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": "NC",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5913612",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Novant Health Granite Quarry Internal Medicine & Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Novant Health Granite Quarry Internal Medicine & Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Salisbury, NC

All providers in Salisbury, NC · Family Medicine Physician in North Carolina

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 10, 2023. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider 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.