Basic Information
| Provider Information | |||||||||
| NPI: | 1770753444 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLMONT PHYSICIAN SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KINGSPORT HEMATOLOGY/ONCOLOGY | ||||||||
| 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: | 111 W STONE DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243150 | ||||||||
| FaxNumber: | 4232243169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2008 | ||||||||
| LastUpdateDate: | 03/04/2010 | ||||||||
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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, CPC-I | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | TN | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.