Basic Information
Provider Information | |||||||||
NPI: | 1083069017 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CAROMONT MEDICAL GROUP INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CAROMONT PULMONARY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 744786 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303744786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7048342450 | ||||||||
FaxNumber: | 7046715331 | ||||||||
Practice Location | |||||||||
Address1: | 934 COX RD | ||||||||
Address2: |   | ||||||||
City: | GASTONIA | ||||||||
State: | NC | ||||||||
PostalCode: | 280543456 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9808345864 | ||||||||
FaxNumber: | 7048640288 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2016 | ||||||||
LastUpdateDate: | 08/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OCONNOR | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7048342049 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CAROMONT MEDICAL GROUP INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.