Provider Demographics
NPI:1093005159
Name:CAROMONT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CAROMONT MEDICAL GROUP INC
Other - Org Name:ADULT PRIMARY AND PREVENTIVE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-671-5343
Mailing Address - Street 1:1040 X RAY DR STE B
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7488
Mailing Address - Country:US
Mailing Address - Phone:704-884-0064
Mailing Address - Fax:704-884-0074
Practice Address - Street 1:1040 X RAY DR
Practice Address - Street 2:SUITE B
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5438
Practice Address - Country:US
Practice Address - Phone:704-884-0064
Practice Address - Fax:704-884-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917719Medicaid
NC2315463Medicare PIN