NPIMap

Organization Active NPI

Novant Health Medical Group, LLC

Doing business as Novant Health Pediatrics SouthPark

  • Pediatrics Physician
  • Charlotte, NC
National Provider Identifier
1467490102
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
Doing business as
Novant Health Pediatrics SouthPark
Practice address
6324 Fairview Rd
Suite 350
Charlotte, NC 28210-4171
Phone
(704) 384-8600
Fax
(704) 384-8610
NPI assigned
Jun 3, 2006
Last updated
Jun 20, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 20, 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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X NC Primary

Addresses

Primary practice location

6324 Fairview Rd
Suite 350
Charlotte, NC 28210-4171

Mailing address

PO Box 60447
Charlotte, NC 28260-0447
Phone (704) 384-8600

Other identifiers 3

IdentifierTypeStateIssuer
890273WMedicaidNC
0273WOtherNCBCBS NC
NPA712MedicaidSC

Other names 1

  • Novant Health Pediatrics SouthPark 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

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
34D0244004Novant Health Pediatrics - Southpark6324 Fairview Road, Suite 350, Charlotte, NC 28210Certificate of waiverFeb 11, 2028

National Provider Directory

National Provider Directory
Tax ID family
Presbyterian Specialty503 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

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1149292800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1718841600000",
    "number": "1467490102",
    "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": "704-384-8600",
            "fax_number": "704-384-8610"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6324 FAIRVIEW RD",
            "address_2": "SUITE 350",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282104171",
            "telephone_number": "704-384-8600",
            "fax_number": "704-384-8610"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NOVANT HEALTH MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-03",
        "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": "",
            "desc": "Pediatrics",
            "state": "NC",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "890273W",
            "state": "NC"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS NC",
            "identifier": "0273W",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "NPA712",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Novant Health Pediatrics SouthPark",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Novant Health Pediatrics SouthPark",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Charlotte, 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.