Provider Demographics
NPI:1619164365
Name:MOUNTAINEER GASTROENTEROLOGY INC
Entity Type:Organization
Organization Name:MOUNTAINEER GASTROENTEROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:CORTELLESI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:276-596-9980
Mailing Address - Street 1:4035 COLLEGE AVENUE
Mailing Address - Street 2:#102
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605
Mailing Address - Country:US
Mailing Address - Phone:276-596-9980
Mailing Address - Fax:276-596-9981
Practice Address - Street 1:1100 CEDAR VALLEY DR,
Practice Address - Street 2:
Practice Address - City:CEDAR BLUFF
Practice Address - State:VA
Practice Address - Zip Code:24609
Practice Address - Country:US
Practice Address - Phone:276-596-9980
Practice Address - Fax:276-596-9981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1732207RG0100X
VA0102037199207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty