Provider Demographics
NPI:1972747053
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:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:OCONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-834-2049
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2555 COURT DRIVE
Practice Address - Street 2:SUITE 450
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-671-7652
Practice Address - Fax:704-671-7656
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROMONT MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-21
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911868Medicaid
NC2315463Medicare PIN