Basic Information
Provider Information
NPI: 1952580557
EntityType: 2
ReplacementNPI:  
OrganizationName: CAROMONT MEDICAL GROUP INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: CAROMONT FAMILY MEDICINE
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 744786
Address2:  
City: ATLANTA
State: GA
PostalCode: 303744786
CountryCode: US
TelephoneNumber: 7048254750
FaxNumber: 7048256985
Practice Location
Address1: 4235 S. NEW HOPE ROAD
Address2: SUITE A
City: GASTONIA
State: NC
PostalCode: 280568453
CountryCode: US
TelephoneNumber: 7048254750
FaxNumber: 7048256985
Other Information
ProviderEnumerationDate: 10/31/2007
LastUpdateDate: 02/17/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: OCONNOR
AuthorizedOfficialFirstName: DAVID
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CFO
AuthorizedOfficialTelephone: 7048342049
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/17/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
890138P05NC MEDICAID


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