Provider Demographics
NPI:1285940445
Name:CAROMONT MEDICAL GROUP INC
Entity type:Organization
Organization Name:CAROMONT MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:VALINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-834-2133
Mailing Address - Street 1:3845 S. NEW HOPE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-8439
Mailing Address - Country:US
Mailing Address - Phone:704-824-9119
Mailing Address - Fax:704-824-2401
Practice Address - Street 1:3845 S. NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-8439
Practice Address - Country:US
Practice Address - Phone:704-824-9119
Practice Address - Fax:704-824-2401
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROMONT MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-26
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915261Medicaid
NC2315463DMedicare PIN