Provider Demographics
NPI:1225087398
Name:MOUNTAIN-HOME MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:MOUNTAIN-HOME MEDICAL GROUP, PA
Other - Org Name:MTN HOME MEDICAL GROUP PA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAXWELL
Authorized Official - Middle Name:G
Authorized Official - Last Name:CHENEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-425-3125
Mailing Address - Street 1:PO BOX 1836
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-1836
Mailing Address - Country:US
Mailing Address - Phone:870-425-3125
Mailing Address - Fax:870-424-5059
Practice Address - Street 1:353 EAST 8TH STREET
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-425-3125
Practice Address - Fax:870-424-5059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0049207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101002002Medicaid
AR101002002Medicaid