Basic Information
| Provider Information | |||||||||
| NPI: | 1306966601 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROMONT MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | CAROMONT PSYCHIATRIC HOSPITALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2240 REMOUNT RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280544725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046715311 | ||||||||
| FaxNumber: | 7046715308 | ||||||||
| Practice Location | |||||||||
| Address1: | 2240 REMOUNT RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280544725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046715344 | ||||||||
| FaxNumber: | 7046715331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 04/12/2010 | ||||||||
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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 | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 5900254 | 05 | NC | MEDICAID |