Provider Demographics
NPI:1205054327
Name:PINE MOUNTAIN CLINIC PSC
Entity type:Organization
Organization Name:PINE MOUNTAIN CLINIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MADHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-337-6047
Mailing Address - Street 1:850 RIVERVIEW RD
Mailing Address - Street 2:PO BOX 308
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-1430
Mailing Address - Country:US
Mailing Address - Phone:606-337-6047
Mailing Address - Fax:606-337-0925
Practice Address - Street 1:850 RIVERVIEW RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1430
Practice Address - Country:US
Practice Address - Phone:606-337-6047
Practice Address - Fax:606-337-0925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29667207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65930851Medicaid
KY3845Medicare PIN
KY65930851Medicaid