Provider Demographics
NPI: | 1356314272 |
---|---|
Name: | CAROMONT MEDICAL GROUP INC |
Entity Type: | Organization |
Organization Name: | CAROMONT MEDICAL GROUP INC |
Other - Org Name: | |
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: | 2315 COURT DR |
Practice Address - Street 2: | |
Practice Address - City: | GASTONIA |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28054-2151 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-834-2450 |
Practice Address - Fax: | 704-671-5331 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | CAROMONT MEDICAL GROUP INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2006-02-10 |
Last Update Date: | 2022-08-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | Group - Multi-Specialty |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207RH0002X | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207VM0101X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | CA1541 | Other | MEDICARE RAILROAD PIN |
SC | CB6618 | Other | MEDICARE RAILROAD PIN |
SC | 6221 | Medicare PIN | |
NC | CA1541 | Other | MEDICARE RAILROAD PIN |