Provider Demographics
NPI:1790010890
Name:CAROMONT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CAROMONT MEDICAL GROUP INC
Other - Org Name:CAROMONT VASCULAR CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:VALINDA
Authorized Official - Middle Name:
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 450
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2555 COURT DR
Practice Address - Street 2:STE 450
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-07
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5913804Medicaid
NC2315463Medicare PIN