Novant Health Medical Group, LLC

Primary specialty

Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X

Legal business name

NOVANT HEALTH MEDICAL GROUP, LLC

Practice address

6324 Fairview Rd
Ste 390
Charlotte, NC 28210-4173

Phone

(704) 316-1120

Fax

(704) 316-1121

NPI assigned

Jul 15, 2008

Organization subpart

No

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

Addresses

Other identifiers 1

Other names 1

• Novant Health Urogynecology Doing business as

Medicare fee-for-service enrollment

Enrolled in NC

Enrollment records 1

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

CLIA laboratory certificates

Locations

Practitioners 4

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

• Alexa Jay Amin, PA

  • Physician Assistant
  • Winston Salem, NC
  • NPI 1841977378
  NPD
• Joseph Michael Malek, M.D.

  • Obstetrics & Gynecology Physician
  • Huntersville, NC
  • NPI 1205129830
  NPD
• Lori Anne Tackman, MD

  • Pediatrics Physician
  • Supply, NC
  • NPI 1497752968
  NPD
• Tracy Reymore Black, PA-C

  • Physician Assistant
  • Myrtle Beach, SC
  • NPI 1033181193
  NPD

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

{
    "created_epoch": "1216080000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1721088000000",
    "number": "1447414925",
    "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": "704-316-1120",
            "fax_number": "704-316-1121"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6324 FAIRVIEW RD",
            "address_2": "STE 390",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282104173",
            "telephone_number": "704-316-1120",
            "fax_number": "704-316-1121"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "10220 Prosperity Park Dr Ste 300",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282691106",
            "country_code": "US",
            "telephone_number": "704-316-1120",
            "fax_number": "704-316-1121",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "8201 Healthcare Loop Ste 302",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282157072",
            "country_code": "US",
            "telephone_number": "704-316-1120",
            "fax_number": "704-316-1121",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "106 Langtree Village Dr Ste 200",
            "address_purpose": "LOCATION",
            "city": "Mooresville",
            "state": "NC",
            "postal_code": "281177594",
            "country_code": "US",
            "telephone_number": "704-384-7101",
            "fax_number": "704-384-7102",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "9930 Kincey Ave Ste 220",
            "address_purpose": "LOCATION",
            "city": "Huntersville",
            "state": "NC",
            "postal_code": "280786541",
            "country_code": "US",
            "telephone_number": "704-316-1120",
            "fax_number": "704-384-1461",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "6324 Fairview Rd Ste 420",
            "address_purpose": "LOCATION",
            "city": "Charlotte",
            "state": "NC",
            "postal_code": "282103372",
            "country_code": "US",
            "telephone_number": "704-316-1120",
            "fax_number": "704-316-1121",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "NOVANT HEALTH MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-07-15",
        "last_updated": "2024-07-16",
        "certification_date": "2024-07-16",
        "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": "207V00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207VF0040X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology, Urogynecology and Reconstructive Pelvic Surgery",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1447414925",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Novant Health Urogynecology",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Novant Health Urogynecology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Novant Health Medical Group, LLC
• Novant Health Medical Group, LLC
• Novant Health Medical Group, LLC
• Novant Health Medical Group, LLC
• Novant Health Medical Group, LLC
• Novant Health Medical Group, LLC
• Novant Health Medical Group, LLC
• Novant Health Medical Group, LLC
• Novant Health Medical Group, LLC
• Novant Health Medical Group, LLC

• Obstetrics & Gynecology Physician in Charlotte, NC
• Providers in Charlotte, NC by specialty
• Obstetrics & Gynecology Physician in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 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.