Basic Information
| Provider Information | |||||||||
| NPI: | 1285680819 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLMONT PHYSICIAN SERVICES INC | ||||||||
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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: | 999 EXECUTIVE PARK BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243250 | ||||||||
| FaxNumber: | 4232243258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 09/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOCKE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4232243289 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CPC, CCS-P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 363LP0200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363AM0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 367500000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207RH0003X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RI0200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207VM0101X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine | 363AS0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1527279 | 01 | TN | UMWA | OTHER | 3709584 | 05 | TN | MEDICAID | 65931099 | 05 | KY | MEDICAID | 23305008 | 01 | TN | FEDERAL BLACK LUNG | OTHER |