Provider Demographics
NPI:1467565804
Name:MOUNTAIN REGION FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:MOUNTAIN REGION FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-224-3400
Mailing Address - Street 1:142 MEADE AVENUE
Mailing Address - Street 2:
Mailing Address - City:NICKELSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24271
Mailing Address - Country:US
Mailing Address - Phone:276-479-2201
Mailing Address - Fax:276-479-3314
Practice Address - Street 1:142 MEADE AVENUE
Practice Address - Street 2:
Practice Address - City:NICKELSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24271
Practice Address - Country:US
Practice Address - Phone:276-479-2201
Practice Address - Fax:276-479-3314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4175553Medicaid
VA037069OtherBLUE CROSS BLUE SHIELD
265967710OtherTRICARE/CHAMPUS
VA5609933Medicaid
TN0040096OtherBLUE CROSS BLUE SHIELD
VA5609933Medicaid
TN4175553Medicaid