Provider Demographics
NPI:1407035025
Name:CAROMONT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CAROMONT MEDICAL GROUP INC
Other - Org Name:CAROMONT FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PRACTICE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUNKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-834-2135
Mailing Address - Street 1:14035 GRANDIFLORA DRIVE
Mailing Address - Street 2:STE B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-8456
Mailing Address - Country:US
Mailing Address - Phone:704-583-1155
Mailing Address - Fax:704-504-2495
Practice Address - Street 1:14035 GRANDIFLORA DRIVE
Practice Address - Street 2:STE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28278-8456
Practice Address - Country:US
Practice Address - Phone:704-583-1155
Practice Address - Fax:704-504-2495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906334Medicaid
NC5906334Medicaid