Provider Demographics
NPI:1366504789
Name:MOUNTAIN MEDICAL SPECIALISTS, PC
Entity Type:Organization
Organization Name:MOUNTAIN MEDICAL SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:D
Authorized Official - Last Name:HIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-754-5191
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-0016
Mailing Address - Country:US
Mailing Address - Phone:706-754-5191
Mailing Address - Fax:706-754-1725
Practice Address - Street 1:207 ADAMS DR
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535-4501
Practice Address - Country:US
Practice Address - Phone:706-754-5191
Practice Address - Fax:706-754-5191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA26375207R00000X, 207RS0010X
GARN124242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000300605DMedicaid
GA110104731OtherRAILROAD MEDICARE
GAD42109OtherSANDERS UPIN NUMBER
GA194840OtherWELLCARE VENDOR NUMBER
GAGRP2225Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER