Provider Demographics
NPI:1659303196
Name:MOUNTAINEER FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:MOUNTAINEER FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BLAIR
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-842-1035
Mailing Address - Street 1:PO BOX 119
Mailing Address - Street 2:916 WEST MAIN STREET
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-0119
Mailing Address - Country:US
Mailing Address - Phone:304-842-1035
Mailing Address - Fax:
Practice Address - Street 1:916 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-0119
Practice Address - Country:US
Practice Address - Phone:304-842-1035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV1976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005030Medicaid
WV001875187OtherMOUNTAIN STATE BCBS
WV9359331Medicare PIN