Basic Information
| Provider Information | |||||||||
| NPI: | 1104286194 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLMONT MEDICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 4485 W STONE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376601050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243150 | ||||||||
| FaxNumber: | 4232243169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2016 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | DOUGAN | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | WHS SR VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4232308512 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.