Basic Information
Provider Information | |||||||||
NPI: | 1689032575 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLMONT MEDICAL ASSOCIATES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BALLAD HEALTH MEDICAL ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 405 SCENIC DR | ||||||||
Address2: | SUITE A | ||||||||
City: | ROGERSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 378572441 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4239213490 | ||||||||
FaxNumber: | 4232727667 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/05/2016 | ||||||||
LastUpdateDate: | 04/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALLFORD | ||||||||
AuthorizedOfficialFirstName: | CINDY | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROFESSIONAL BILLING | ||||||||
AuthorizedOfficialTelephone: | 4234087220 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.