Basic Information
| Provider Information | |||||||||
| NPI: | 1649404294 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROMONT MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CAROLINA CARDIOVASCULAR AND THORACIC SURGERY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2555 COURT DR | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046717670 | ||||||||
| FaxNumber: | 7046717672 | ||||||||
| Practice Location | |||||||||
| Address1: | 2555 COURT DR | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046717670 | ||||||||
| FaxNumber: | 7046717672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2009 | ||||||||
| LastUpdateDate: | 05/12/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHOVELIN | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 7048342133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.