Provider Demographics
NPI:1972602894
Name:DRS MONTENEGRO & DE WIT
Entity Type:Organization
Organization Name:DRS MONTENEGRO & DE WIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DE WIT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-928-3051
Mailing Address - Street 1:310 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6008
Mailing Address - Country:US
Mailing Address - Phone:423-928-3051
Mailing Address - Fax:423-928-8840
Practice Address - Street 1:310 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 201
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6008
Practice Address - Country:US
Practice Address - Phone:423-928-3051
Practice Address - Fax:423-928-8840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN013647174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN15491OtherBCBS
TN3382675Medicaid
TN129760OtherTRIGON BCBS
TN15491OtherBCBS
TNCB4766Medicare ID - Type UnspecifiedRAILROAD MEDICARE