Provider Demographics
NPI:1720377625
Name:CAROMONT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CAROMONT MEDICAL GROUP, INC.
Other - Org Name:CAROLINAS PLASTIC SURGERY CENTER
Other - Org Type:Doing Business As
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 1:2391 COURT DR
Practice Address - Street 2:SUITE 120B
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2196
Practice Address - Country:US
Practice Address - Phone:704-874-0095
Practice Address - Fax:704-866-8680
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROMONT MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-31
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1720377625Medicaid
NC024W3OtherBCBS