Basic Information
| Provider Information | |||||||||
| NPI: | 1932388568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROMONT- SOUTH POINT LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH POINT FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 159 E DALLAS RD | ||||||||
| Address2: | |||||||||
| City: | STANLEY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281642052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042630300 | ||||||||
| FaxNumber: | 7042631873 | ||||||||
| Practice Location | |||||||||
| Address1: | 159 E DALLAS RD | ||||||||
| Address2: | |||||||||
| City: | STANLEY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281642052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042630300 | ||||||||
| FaxNumber: | 7042631873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | OCONNOR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7048342133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5905652 | 05 | NC | MEDICAID |