NPIMap

Organization Active NPI

Novant Health Medical Group, LLC

  • Psychiatry Physician
  • Shallotte, NC
National Provider Identifier
1124579750
Registry record updated Jun 24, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
NOVANT HEALTH MEDICAL GROUP, LLC
Practice address
512 Village Rd Ste 104
Shallotte, NC 28470-3409
Phone
(910) 721-4200
Fax
(910) 754-3811
NPI assigned
Oct 19, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 24, 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
PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103T00000X
Psychiatry PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 2084P0800X Primary

Addresses

Primary practice location

512 Village Rd Ste 104
Shallotte, NC 28470-3409

Mailing address

PO Box 60447
Charlotte, NC 28260-0447
Phone (910) 721-4200

Other practice location 1

204 Smith Ave
Shallotte, NC 28470-4458
Phone (910) 721-4200

Other practice location 2

584 Hospital Dr NE
Suite A
Bolivia, NC 28422-0019
Phone (704) 316-7585

Other names 1

  • Novant Health Psychiatric Medicine Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
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

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1476835200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1719187200000",
    "number": "1124579750",
    "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": "910-721-4200",
            "fax_number": "910-721-4209"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "512 VILLAGE RD STE 104",
            "city": "SHALLOTTE",
            "state": "NC",
            "postal_code": "284703409",
            "telephone_number": "910-721-4200",
            "fax_number": "910-754-3811"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "204 Smith Ave",
            "address_purpose": "LOCATION",
            "city": "Shallotte",
            "state": "NC",
            "postal_code": "284704458",
            "country_code": "US",
            "telephone_number": "910-721-4200",
            "fax_number": "910-721-4209",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "584 Hospital Dr NE",
            "address_2": "Suite A",
            "address_purpose": "LOCATION",
            "city": "Bolivia",
            "state": "NC",
            "postal_code": "284220019",
            "country_code": "US",
            "telephone_number": "704-316-7585",
            "fax_number": "704-338-6422",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "NOVANT HEALTH MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-10-19",
        "last_updated": "2024-06-24",
        "certification_date": "2024-06-24",
        "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": "103T00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Novant Health Psychiatric Medicine",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Novant Health Psychiatric Medicine",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Shallotte, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 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.