Provider Demographics
NPI:1740863968
Name:WELLMONT MEDICAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:WELLMONT MEDICAL ASSOCIATES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KRUTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3423
Mailing Address - Street 1:311 PRINCETON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2080
Mailing Address - Country:US
Mailing Address - Phone:423-302-6239
Mailing Address - Fax:423-302-6248
Practice Address - Street 1:301 MED TECH PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2630
Practice Address - Country:US
Practice Address - Phone:423-302-6239
Practice Address - Fax:423-302-6248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-05
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory