Provider Demographics
NPI:1710990601
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:
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-230-2109
Mailing Address - Street 1:101 PROFESSIONAL PARK PVT DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2288
Mailing Address - Country:US
Mailing Address - Phone:423-239-7300
Mailing Address - Fax:423-239-8581
Practice Address - Street 1:101 PROFESSIONAL PARK PVT DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2288
Practice Address - Country:US
Practice Address - Phone:423-239-7300
Practice Address - Fax:423-239-8581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN020189600OtherFBL
TN3706159Medicaid
TN31378070OtherDOL
TN020189600OtherFBL
TN3706159Medicare PIN