Healthcare Provider Details

I. General information

NPI: 1124091053
Provider Name (Legal Business Name): CAROMONT SPECIALTY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR SUITE 200
GASTONIA NC
28054-2134
US

IV. Provider business mailing address

PO BOX 550970
GASTONIA NC
28055-0970
US

V. Phone/Fax

Practice location:
  • Phone: 704-671-7670
  • Fax: 704-671-7672
Mailing address:
  • Phone: 704-671-5311
  • Fax: 704-671-5308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: VALINDA L RUTLEDGE
Title or Position: CEO/PRESIDENT
Credential:
Phone: 704-834-2133