Provider Demographics
NPI: | 1619095403 |
---|---|
Name: | WELLMONT PHYSICIAN SERVICES INC |
Entity Type: | Organization |
Organization Name: | WELLMONT PHYSICIAN SERVICES INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | BILLING ADMINISTRATOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CINDY |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | LOCKE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | CPC CCS-P |
Authorized Official - Phone: | 423-224-3250 |
Mailing Address - Street 1: | 999 EXECUTIVE PARK BLVD |
Mailing Address - Street 2: | SUITE 201 |
Mailing Address - City: | KINGSPORT |
Mailing Address - State: | TN |
Mailing Address - Zip Code: | 37660-4632 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 423-224-3250 |
Mailing Address - Fax: | 423-224-3258 |
Practice Address - Street 1: | 1990 HOLTON AVE E |
Practice Address - Street 2: | |
Practice Address - City: | BIG STONE GAP |
Practice Address - State: | VA |
Practice Address - Zip Code: | 24219-3350 |
Practice Address - Country: | US |
Practice Address - Phone: | 423-224-3250 |
Practice Address - Fax: | 423-224-3257 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-03-27 |
Last Update Date: | 2010-11-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207VG0400X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | Group - Multi-Specialty |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
No | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 6593109900 | Medicaid | |
KY | 6590412000 | Medicaid | |
KY | 6594222900 | Medicaid | |
KY | 7100034130 | Medicaid | |
VA | 023305008 | Other | FEDERAL BLACK LUNG |
KY | 7100034130 | Medicaid | |
KY | 6594222900 | Medicaid | |
KY | 6593109900 | Medicaid | |
KY | 6590412000 | Medicaid |