Provider Demographics
NPI: | 1881023117 |
---|---|
Name: | APPALACHIAN MOUNTAINS MEDICAL, LLC |
Entity Type: | Organization |
Organization Name: | APPALACHIAN MOUNTAINS MEDICAL, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | PATRICIA |
Authorized Official - Middle Name: | PEMBERTON |
Authorized Official - Last Name: | KEITH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 304-719-8658 |
Mailing Address - Street 1: | 123 HUNTERS RIDGE RD |
Mailing Address - Street 2: | |
Mailing Address - City: | FAYETTEVILLE |
Mailing Address - State: | WV |
Mailing Address - Zip Code: | 25840-6655 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 304-574-4384 |
Mailing Address - Fax: | 304-574-4384 |
Practice Address - Street 1: | 454 MCDOWELL ST |
Practice Address - Street 2: | |
Practice Address - City: | WELCH |
Practice Address - State: | WV |
Practice Address - Zip Code: | 24801-2029 |
Practice Address - Country: | US |
Practice Address - Phone: | 304-436-8685 |
Practice Address - Fax: | 304-436-6380 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-11-07 |
Last Update Date: | 2016-08-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | Group - Multi-Specialty | |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207QG0300X | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | Group - Multi-Specialty |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 2085B0100X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | 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 |