Novant Health Medical Group, LLC
Organization Active NPI Family Medicine Physician · Charlotte, NC
NPI 1770511313 · NPPES record last updated Jul 9, 2024
Key facts
- NPI
- 1770511313
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- NOVANT HEALTH MEDICAL GROUP, LLC
- Practice address
- 6324 Fairview Road
Suite 201
Charlotte, NC 28210-4278 - Phone
- (704) 384-0588
- Fax
- (704) 384-0580
- NPI assigned
- Jun 30, 2006
- Organization subpart
- No
Authorized official
- Name
- Leea Jeanine Walton
- Title
- RCS Manager
- Phone
- (704) 316-6081
Practitioners 28
-
Jazmine Chanel Ackerman, FNP-C
-
Amy Lowery Alexanian, M.D.
-
Emily Anne Anastasi, PA-C
-
Lauren Leander Cook, PA-C
-
James Desimone, FNP
-
Karen Elizabeth Lewis, M.D.
-
Natalie Sarah Miller, PAC
-
Pacharo Sally Ndupu, FNP-C
-
Amy Dietzen Petticrew, PA-C
-
Taisha C'Mone Roberts, M.D.
-
Sarah Jordyn-Mary Street, FNP-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 34D1053256 | Novant Health South Park Family Physicians | Compliance | Jul 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NC
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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
Locations
8820 Rachel Freeman Way
Charlotte, NC 28278
Phone (704) 316-3608
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes |
Addresses
Primary practice location
6324 Fairview Road
Suite 201
Charlotte, NC 28210-4278
Mailing address
PO Box 60447
Charlotte, NC 28260-0447
Phone (704) 384-0588
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| CC5118 | Other | NC | RAILROAD MEDICARE |
| 017X3 | Other | NC | BCBS NC |
| NPB165 | Medicaid | SC | |
| 5903451 | Medicaid | NC |
Other names
- Novant Health South Park Family Physicians
Other providers in Charlotte, NC
- 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
All providers in Charlotte, NC · Family Medicine Physician in North Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 9, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.