Provider Demographics
NPI:1740292366
Name:MOUNTAIN REGION FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:MOUNTAIN REGION FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:REPASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-386-3411
Mailing Address - Street 1:390 KANE ST
Mailing Address - Street 2:
Mailing Address - City:GATE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:24251-2753
Mailing Address - Country:US
Mailing Address - Phone:276-386-3411
Mailing Address - Fax:276-386-3492
Practice Address - Street 1:390 KANE ST
Practice Address - Street 2:
Practice Address - City:GATE CITY
Practice Address - State:VA
Practice Address - Zip Code:24251-3407
Practice Address - Country:US
Practice Address - Phone:276-386-3411
Practice Address - Fax:276-286-2492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3908OtherRAILROAD MEDICARE
TN4401019Medicaid
037070OtherANTHEM BLUE CROSS
TN3706150Medicare PIN
VAC04219Medicare PIN