Provider Demographics
NPI:1437387750
Name:CAROMONT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CAROMONT MEDICAL GROUP INC
Other - Org Name:DALLAS INTERNAL 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 1:701 W TRADE ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-1544
Mailing Address - Country:US
Mailing Address - Phone:704-922-3106
Mailing Address - Fax:704-922-1369
Practice Address - Street 1:701 W TRADE ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-1544
Practice Address - Country:US
Practice Address - Phone:704-922-3106
Practice Address - Fax:704-922-1369
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROMONT MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-25
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911865Medicaid
NC5911865Medicaid