Provider Demographics
| NPI: | 1780986257 |
|---|---|
| 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: | SHANE |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | HILTON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 423-302-3467 |
| Mailing Address - Street 1: | 2020 BROOKSIDE DR |
| Mailing Address - Street 2: | |
| Mailing Address - City: | KINGSPORT |
| Mailing Address - State: | TN |
| Mailing Address - Zip Code: | 37660-4633 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 423-343-0434 |
| Mailing Address - Fax: | 423-343-0435 |
| Practice Address - Street 1: | 105 W STONE DR |
| Practice Address - Street 2: | SUITE 6A |
| Practice Address - City: | KINGSPORT |
| Practice Address - State: | TN |
| Practice Address - Zip Code: | 37660 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 423-408-7220 |
| Practice Address - Fax: | 423-408-7405 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2010-12-03 |
| Last Update Date: | 2024-04-19 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RH0002X | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | Group - Multi-Specialty |
| No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | Group - Multi-Specialty |
| No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207VM0101X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | Group - Multi-Specialty |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| TN | 103G705049 | Medicare PIN |
