Provider Demographics
NPI:1164603189
Name:CAROMONT SPECIALTY GROUP LLC
Entity Type:Organization
Organization Name:CAROMONT SPECIALTY GROUP LLC
Other - Org Name:CAROLINA HEART SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:VALINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUTLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-834-2133
Mailing Address - Street 1:2555 COURT DR
Mailing Address - Street 2:STE 200
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2134
Mailing Address - Country:US
Mailing Address - Phone:704-671-7670
Mailing Address - Fax:704-671-7622
Practice Address - Street 1:2555 COURT DR
Practice Address - Street 2:STE 200
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2134
Practice Address - Country:US
Practice Address - Phone:704-671-7670
Practice Address - Fax:704-671-7622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900551Medicaid
NC5900551Medicaid