Basic Information
| Provider Information | |||||||||
| NPI: | 1679863732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROMONT MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | ASHLEY WOMEN'S CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 E GARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280545115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048657416 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 E GARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280545115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048657416 | ||||||||
| FaxNumber: | 7048657232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 03/28/2012 | ||||||||
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| AuthorizedOfficialLastName: | KELLEY | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 7048342133 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROMONT MEDICAL GROUP INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 5917946 | 05 | NC | MEDICAID |