Provider Demographics
NPI:1033166350
Name:MOUNTAIN COMPREHENSIVE HEALTH CORPORATION
Entity Type:Organization
Organization Name:MOUNTAIN COMPREHENSIVE HEALTH CORPORATION
Other - Org Name:MOUNTAIN COMPREHENSIVE SPECIALTY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:L.M. (MIKE)
Authorized Official - Middle Name:
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-633-4823
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858-0070
Mailing Address - Country:US
Mailing Address - Phone:606-633-4823
Mailing Address - Fax:606-633-1874
Practice Address - Street 1:226 MEDICAL PLAZA LN
Practice Address - Street 2:
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-7425
Practice Address - Country:US
Practice Address - Phone:606-633-4871
Practice Address - Fax:606-633-1874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-30
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65933871Medicaid
KY65933871Medicaid