Provider Demographics
NPI:1952691016
Name:CAROMONT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CAROMONT MEDICAL GROUP INC
Other - Org Name:GASTONIA SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-834-2133
Mailing Address - Street 1:2544 COURT DR
Mailing Address - Street 2:STE H
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-3450
Mailing Address - Country:US
Mailing Address - Phone:704-864-7821
Mailing Address - Fax:704-884-0087
Practice Address - Street 1:2544 COURT DR
Practice Address - Street 2:STE H
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-3450
Practice Address - Country:US
Practice Address - Phone:704-864-7821
Practice Address - Fax:704-884-0087
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROMONT MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-11
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC024W5OtherBCBS
NC5917956Medicaid
NC5917956Medicaid