Provider Demographics
NPI:1376575035
Name:WELLMONT CARDIOLOGY SERVICES
Entity Type:Organization
Organization Name:WELLMONT CARDIOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, ISHN NETWORK MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-6565
Mailing Address - Street 1:2050 MEADOWVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-7475
Mailing Address - Country:US
Mailing Address - Phone:423-230-5000
Mailing Address - Fax:423-230-5035
Practice Address - Street 1:2050 MEADOWVIEW PARKWAY
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-7332
Practice Address - Country:US
Practice Address - Phone:423-230-5000
Practice Address - Fax:423-230-5097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3382171Medicaid
VA1376575035Medicaid
VADR8098OtherRAILROAD MEDICARE
TN3382170Medicaid
TNDR5963OtherRAILROAD MEDICARE
VA1376575035Medicaid
TN3382170Medicaid