Provider Demographics
NPI:1457913006
Name:CAROMONT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CAROMONT MEDICAL GROUP INC
Other - Org Name:CAROMONT PODIATRY
Other - Org Type:Former Legal Business Name
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:704-671-5343
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 STE 100
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2197
Practice Address - Country:US
Practice Address - Phone:980-834-7300
Practice Address - Fax:980-834-9874
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROMONT MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-03
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02G2BOtherBCBS OF NC
NC1457913006Medicaid