Basic Information
Provider Information | |||||||||
NPI: | 1043339385 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLMONT PHYSICIAN SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OB GYN CLINIC PC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 999 EXECUTIVE PARK BLVD | ||||||||
Address2: | SUITE 201 | ||||||||
City: | KINGSPORT | ||||||||
State: | TN | ||||||||
PostalCode: | 376604632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232243250 | ||||||||
FaxNumber: | 4232243258 | ||||||||
Practice Location | |||||||||
Address1: | 1980 HOLTON AVE E | ||||||||
Address2: | SUITE 301 | ||||||||
City: | BIG STONE GAP | ||||||||
State: | VA | ||||||||
PostalCode: | 242193366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2765230390 | ||||||||
FaxNumber: | 4235235514 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/28/2007 | ||||||||
LastUpdateDate: | 04/22/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOCKE | ||||||||
AuthorizedOfficialFirstName: | CINDY | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 4232243250 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC CCS-P | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 65942757 | 05 | KY |   | MEDICAID |