Provider Demographics
NPI:1093219628
Name:EAST MOUNTAIN HEALTH PHYSICIANS, INC.
Entity Type:Organization
Organization Name:EAST MOUNTAIN HEALTH PHYSICIANS, INC.
Other - Org Name:BENSENHAVER MEDICAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:NEVADA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-536-0103
Mailing Address - Street 1:220 CAMPUS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2889
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:540-536-0235
Practice Address - Street 1:100 HOSPITAL DR STE 1
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-9570
Practice Address - Country:US
Practice Address - Phone:304-257-1944
Practice Address - Fax:304-257-9524
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST MOUNTAIN HEALTH PHYSICIANS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-20
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207Q00000X
207Q00000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty