Provider Demographics
NPI:1891954178
Name:MOUNTAIN VALLEY MEDICAL CENTER
Entity Type:Organization
Organization Name:MOUNTAIN VALLEY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-746-6571
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:DILLARD
Mailing Address - State:GA
Mailing Address - Zip Code:30537-0444
Mailing Address - Country:US
Mailing Address - Phone:706-746-6571
Mailing Address - Fax:706-746-5643
Practice Address - Street 1:92 BETTYS CREEK RD
Practice Address - Street 2:
Practice Address - City:DILLARD
Practice Address - State:GA
Practice Address - Zip Code:30537-2257
Practice Address - Country:US
Practice Address - Phone:706-746-6571
Practice Address - Fax:706-746-5643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00273831B4Medicaid
GAGRP2173Medicare PIN
GA00273831B4Medicaid