1720377625 NPI number — CAROMONT MEDICAL GROUP, INC.

Table of content: (NPI 1720377625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720377625 NPI number — CAROMONT MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROMONT MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720377625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 744786
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-4786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-834-2450
Provider Business Mailing Address Fax Number:
704-671-5331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2391 COURT DR
Provider Second Line Business Practice Location Address:
SUITE 120B
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-2196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-874-0095
Provider Business Practice Location Address Fax Number:
704-866-8680
Provider Enumeration Date:
03/31/2011

Additional Information

Authorized Official

Authorized Official Last Name:
OCONNOR
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
704-834-2049

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1720377625 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 024W3 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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