Basic Information
| Provider Information | |||||||||
| NPI: | 1861671471 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROMONT MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CAROMONT INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 744786 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303744786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048342450 | ||||||||
| FaxNumber: | 7046715331 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 SUMMIT CROSSING PL STE 301 | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048670735 | ||||||||
| FaxNumber: | 7048670738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OCONNOR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7048342049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROMONT MEDICAL GROUP INC | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 890232H | 05 | NC | MEDICAID |