Provider Demographics
NPI:1538661848
Name:EAST MOUNTAIN HEALTH PHYSICIANS, INC.
Entity Type:Organization
Organization Name:EAST MOUNTAIN HEALTH PHYSICIANS, INC.
Other - Org Name:PANHANDLE CARDIOLOGY AND VASCULAR MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:NEVADA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-536-0103
Mailing Address - Street 1:220 CAMPUS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2889
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 TAVERN RD STE 200
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2853
Practice Address - Country:US
Practice Address - Phone:304-264-9485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST MOUNTAIN HEALTH PHYSICIANS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-02
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207RC0000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty