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Novant Health Medical Group, LLC

Organization Active NPI Family Medicine Physician · Wake Forest, NC

NPI 1235458985 · NPPES record last updated Jul 9, 2024

Key facts

NPI
1235458985
Entity type
Organization (NPI type 2)
Primary specialty
Family Medicine Physician 207Q00000X
License
2005-01578 (NC)
Legal business name
NOVANT HEALTH MEDICAL GROUP, LLC
Practice address
10500 Ligon Mill Rd
Suite 113
Wake Forest, NC 27587-4576
Phone
(919) 570-5705
Fax
(919) 570-5710
NPI assigned
May 20, 2010
Organization subpart
Yes
Parent organization (as reported)
NOVANT MEDICAL GROUP, INC

Authorized official

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

Corporate family (same tax ID) 24

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners 1

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

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D2010275Novant Health Primary Care Partners
10500 Ligon Mill Road Ste 113, Wake Forest, NC 27587		Certificate of waiverJul 22, 2028

Medicare participation

Medicare fee-for-service enrollment
Enrolled in NC

Medicare enrollment records

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

Tax ID family
Presbyterian Inpt Care (503 organizations share this tax ID)
Part of
Presbyterian Inpt Care

Locations

10500 Ligon Mill Rd
Ste 113
Wake Forest, NC 27587
Phone (919) 496-1050

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician
Group: 193200000X MULTI-SPECIALTY GROUP		 207Q00000X 2005-01578 NC Yes

Addresses

Primary practice location

10500 Ligon Mill Rd
Suite 113
Wake Forest, NC 27587-4576

Mailing address

PO Box 60447
Charlotte, NC 28260-0447
Phone (919) 570-5705

Other identifiers

IdentifierTypeStateIssuer
5914970MedicaidNC

Other names

  • Novant Health Primary Care Partners 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 9, 2024.

{
    "created_epoch": "1274313600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1720483200000",
    "number": "1235458985",
    "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": "919-570-5705",
            "fax_number": "919-570-5710"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10500 LIGON MILL RD",
            "address_2": "SUITE 113",
            "city": "WAKE FOREST",
            "state": "NC",
            "postal_code": "275874576",
            "telephone_number": "919-570-5705",
            "fax_number": "919-570-5710"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NOVANT HEALTH MEDICAL GROUP, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NOVANT MEDICAL GROUP, INC",
        "enumeration_date": "2010-05-20",
        "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": "2005-01578",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5914970",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Novant Health Primary Care Partners",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Novant Health Primary Care Partners",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wake Forest, NC

All providers in Wake Forest, NC · Family Medicine Physician in North Carolina

Sources for this page

Verify at the official NPI Registry.