Basic Information
| Provider Information | |||||||||
| NPI: | 1003106162 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROMONT MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | CAROMONT HEALTH BARIATRIC SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 550970 | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280550970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048342450 | ||||||||
| FaxNumber: | 7046715331 | ||||||||
| Practice Location | |||||||||
| Address1: | 2711 X RAY DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280547491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046715483 | ||||||||
| FaxNumber: | 7046715452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 06/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | RUTLEDGE | ||||||||
| AuthorizedOfficialFirstName: | VALINDA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 7048342133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROMONT MEDICAL GROUP INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.