Basic Information
| Provider Information | |||||||||
| NPI: | 1710990601 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN REGION FAMILY MEDICINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 PROFESSIONAL PARK PVT DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376632288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232397300 | ||||||||
| FaxNumber: | 4232398581 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PROFESSIONAL PARK PVT DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376632288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232397300 | ||||||||
| FaxNumber: | 4232398581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 12/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | TRENT | ||||||||
| AuthorizedOfficialFirstName: | WANDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4232302109 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 020189600 | 01 | TN | FBL | OTHER | 3706159 | 05 | TN | MEDICAID | 31378070 | 01 | TN | DOL | OTHER |