NPIMap

Organization Active NPI

Novant Health Medical Group, LLC

  • Pediatrics Physician
  • Supply, NC
National Provider Identifier
1235798992
Registry record updated Jun 20, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
NOVANT HEALTH MEDICAL GROUP, LLC
Practice address
20 Medical Campus Dr NW Ste 205
Supply, NC 28462-4094
Phone
(704) 384-0517
NPI assigned
Jun 6, 2019
Organization subpart
No

Authorized official

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

Practitioners 10

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

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D2170564Novant Health Pediatrics - Brunswick20 Medical Campus Drive Suite 205, Supply, NC 28462ComplianceMar 15, 2028

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
Tax ID family
Presbyterian Inpt Care503 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Locations

3213 Rogers Rd
Wake Forest, NC 27587
Phone (919) 562-2288

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208000000X Primary

Addresses

NPPES NPI Registry

Primary practice location

20 Medical Campus Dr NW Ste 205
Supply, NC 28462-4094

Mailing address

PO Box 60447
Charlotte, NC 28260-0447

Other names 1

NPPES NPI Registry
  • Novant Health Pediatrics Brunswick Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Jun 20, 2024.

{
    "created_epoch": "1559779200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1718841600000",
    "number": "1235798992",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20 MEDICAL CAMPUS DR NW STE 205",
            "city": "SUPPLY",
            "state": "NC",
            "postal_code": "284624094",
            "telephone_number": "704-384-0517"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NOVANT HEALTH MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-06-06",
        "last_updated": "2024-06-20",
        "certification_date": "2024-06-20",
        "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": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Novant Health Pediatrics Brunswick",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Novant Health Pediatrics Brunswick",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Supply, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.