Provider Demographics
NPI:1114042629
Name:MOUNTAIN EMPIRE NEUROLOGICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:MOUNTAIN EMPIRE NEUROLOGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-764-0987
Mailing Address - Street 1:3183 W STATE ST
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1712
Mailing Address - Country:US
Mailing Address - Phone:423-761-0987
Mailing Address - Fax:423-652-2512
Practice Address - Street 1:3183 W STATE ST
Practice Address - Street 2:SUITE 1201
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1712
Practice Address - Country:US
Practice Address - Phone:423-761-0987
Practice Address - Fax:423-652-2512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC04525Medicare PIN
VAC04526Medicare PIN