Basic Information
| Provider Information | |||||||||
| NPI: | 1114045903 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLMONT PHYSICIAN SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHWEST VA REGIONAL CANCER CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 611 TRENT ST NE | ||||||||
| Address2: | |||||||||
| City: | NORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242731533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766795874 | ||||||||
| FaxNumber: | 2766796912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 04/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOCKE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4232243250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC CCS-P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 109871003 | 01 | VA | DMERC | OTHER | 65931099 | 05 | KY | MEDICAID | 023305000 | 01 | VA | FEDERAL BLACK LUNG | OTHER | 1008035 | 01 | VA | UMWA | OTHER |