Basic Information
| Provider Information | |||||||||
| NPI: | 1922398080 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROMONT MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | THE HAND CENTER OF THE CAROLINAS | ||||||||
| 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: | 2391 COURT DR | ||||||||
| Address2: | SUITE 120A | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048668976 | ||||||||
| FaxNumber: | 7048668680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| 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 | 2086S0105X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand |
ID Information
| ID | Type | State | Issuer | Description | 5918099 | 05 | NC | MEDICAID |