Basic Information
| Provider Information | |||||||||
| NPI: | 1164603189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROMONT SPECIALTY GROUP LLC | ||||||||
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| OtherOrganizationName: | CAROLINA HEART SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 COURT DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046717670 | ||||||||
| FaxNumber: | 7046717622 | ||||||||
| Practice Location | |||||||||
| Address1: | 2555 COURT DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046717670 | ||||||||
| FaxNumber: | 7046717622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 10/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | RUTLEDGE | ||||||||
| AuthorizedOfficialFirstName: | VALINDA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 7048342133 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 5900551 | 05 | NC | MEDICAID |