Provider Demographics
NPI:1962498899
Name:MOUNTAIN MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:MOUNTAIN MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:PADMAJA
Authorized Official - Middle Name:PAM
Authorized Official - Last Name:POLAVARAPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-688-4800
Mailing Address - Street 1:144 SEDDON ST
Mailing Address - Street 2:
Mailing Address - City:BLAND
Mailing Address - State:VA
Mailing Address - Zip Code:24315-5365
Mailing Address - Country:US
Mailing Address - Phone:276-688-4800
Mailing Address - Fax:276-688-4805
Practice Address - Street 1:144 SEDDON ST
Practice Address - Street 2:
Practice Address - City:BLAND
Practice Address - State:VA
Practice Address - Zip Code:24315-5365
Practice Address - Country:US
Practice Address - Phone:276-688-4800
Practice Address - Fax:276-688-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F67099Medicare UPIN