MEDICARE: CAROMONT MEDICAL GROUP INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1972301380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROMONT MEDICAL GROUP INC

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

Provider Business Practice Location Address
First Line	:	159 E DALLAS RD STE B
Second Line	:
City	:	STANLEY
State	:	NC
Zip	:	28164-2052
Country	:	US
Telephone Number	:	980-834-5230
Fax Number	:	980-834-9898

Authorized Official
Title or Position	:	CFO
Name	:	DAVID M OCONNOR
Credential	:
Telephone Number	:	704-671-5343

Provider Enumeration Date	:	03/04/2025
Last Update Date	:	03/04/2025

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