Provider Demographics
NPI:1831467067
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:MS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:TRENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-230-2109
Mailing Address - Street 1:444 CLINCHFIELD STREET
Mailing Address - Street 2:STE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3683
Mailing Address - Country:US
Mailing Address - Phone:423-230-2100
Mailing Address - Fax:423-230-2112
Practice Address - Street 1:444 CLINCHFIELD STREET
Practice Address - Street 2:STE 201
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3683
Practice Address - Country:US
Practice Address - Phone:423-230-2100
Practice Address - Fax:423-230-2112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2017-03-10
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
1003827205OtherNPI
1538110309OtherNPI
1154354900OtherNPI
1164582862OtherNPI
1528079910OtherNPI
1548252638OtherNPI
TN1861732968OtherNPI
TN1881854594OtherNPI
1356391098OtherNPI
1477539542OtherNPI
TN1526748Medicaid
1629089784OtherNPI
1770534539OtherNPI
1306897202OtherNPI
1588676456OtherNPI
3386406OtherMEDICARE PTAN (S. STEFFEY)
TN4312365OtherBLUE CROSS BLUE SHIELD GROUP
TN103I089618Medicare PIN
1548252638OtherNPI
1629089784OtherNPI
1538110309OtherNPI
TN103I087714Medicare PIN
1528079910OtherNPI
TN3305857Medicare PIN
TN103I89614Medicare PIN
3386406OtherMEDICARE PTAN (S. STEFFEY)
1306897202OtherNPI
1164582862OtherNPI
TN1861732968OtherNPI
1003827205OtherNPI
TN103G706781Medicare PIN