Caromont Medical Group, Inc.
Organization Active NPI Family Medicine Physician · Lake Wylie, SC
NPI 1609467760 · NPPES record last updated Aug 9, 2022
Key facts
- NPI
- 1609467760
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- CAROMONT MEDICAL GROUP, INC.
- Practice address
- 1201 Village Harbor Dr Ste 104
Lake Wylie, SC 29710-9276 - Phone
- (803) 831-6859
- Fax
- (803) 831-6860
- NPI assigned
- Feb 1, 2021
- Organization subpart
- Yes
- Parent organization (as reported)
- CAROMONT MEDICAL GROUP INC
Authorized official
- Name
- David Michael Oconnor
- Title
- Cfo
- Phone
- (704) 834-2049
Other NPIs on the same Medicare enrollment 8
Practitioners 17
-
Kellie Walker Perez, DNP, FNP
-
Kofi Asiedu, NP
-
Alvina Elaine Bryant, FNP-C
-
Sylvia Cierraann Campbell, FNP-C
-
Michelle Cardona, FNP
-
James Mitchell Costner, M.D.
-
Elliott Bradley Courter, D.O.
-
Meghan Prevette Crater, FNP-C
-
Hallie Kathryn Spears Gunst, FNP-BC
-
Kelly Ann Hoyle, FNP-C
-
Tonya Coleman Lane, FNP-C
-
Crystal Cornelia Maddox, M.D.
-
Sydni Rhea Noble, FNP-C
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 42D2213658 | Caromont Urgent Care-Lake Wylie | Certificate of waiver | Feb 15, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in SC
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20041021000318 | SC | Part B Supplier - Clinic/Group Practice | 3577476258 |
Receives reassigned benefits from 59 practitioners 8 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Clover, SC; Lake Wylie, SC |
National Provider Directory
- Part of
- Gaston Health Resources
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | Yes |
Addresses
Primary practice location
1201 Village Harbor Dr Ste 104
Lake Wylie, SC 29710-9276
Mailing address
PO Box 744786
Atlanta, GA 30374-4786
Phone (704) 834-2450
Other names
- CaroMont Urgent Care
NPI Registry JSON
{
"created_epoch": "1612137600000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1660003200000",
"number": "1609467760",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 744786",
"city": "ATLANTA",
"state": "GA",
"postal_code": "303744786",
"telephone_number": "704-834-2450",
"fax_number": "704-671-5331"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1201 VILLAGE HARBOR DR STE 104",
"city": "LAKE WYLIE",
"state": "SC",
"postal_code": "297109276",
"telephone_number": "803-831-6859",
"fax_number": "803-831-6860"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "CAROMONT MEDICAL GROUP, INC.",
"organizational_subpart": "YES",
"parent_organization_legal_business_name": "CAROMONT MEDICAL GROUP INC",
"enumeration_date": "2021-02-01",
"last_updated": "2022-08-09",
"certification_date": "2022-08-09",
"status": "A",
"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"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
"desc": "Family Medicine",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "CaroMont Urgent Care",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "CaroMont Urgent Care",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Lake Wylie, SC
- Geneva Michelle Bolen
- Laura Bradshaw
- Brooke Osterhoudt, LLC
- Allison Kay Bull
- Carolina Family Dentistry at Lake Wylie
- Jenna Carter
- Monie B Clifton
- Kristen Carter Cole
- Kannesha Coleman
- Melissa Colon
All providers in Lake Wylie, SC · Family Medicine Physician in South Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 9, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.