Basic Information
| Provider Information | |||||||||
| NPI: | 1831467067 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN REGION FAMILY MEDICINE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 CLINCHFIELD STREET | ||||||||
| Address2: | STE 201 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232302100 | ||||||||
| FaxNumber: | 4232302112 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 CLINCHFIELD STREET | ||||||||
| Address2: | STE 201 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232302100 | ||||||||
| FaxNumber: | 4232302112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2011 | ||||||||
| LastUpdateDate: | 03/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | TRENT | ||||||||
| AuthorizedOfficialFirstName: | WANDA | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4232302109 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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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 | 1003827205 | 01 | NPI | OTHER | 1538110309 | 01 | NPI | OTHER | 1154354900 | 01 | NPI | OTHER | 1164582862 | 01 | NPI | OTHER | 1528079910 | 01 | NPI | OTHER | 1548252638 | 01 | NPI | OTHER | 1861732968 | 01 | TN | NPI | OTHER | 1881854594 | 01 | TN | NPI | OTHER | 1356391098 | 01 | NPI | OTHER | 1477539542 | 01 | NPI | OTHER | 1526748 | 05 | TN | MEDICAID | 1629089784 | 01 | NPI | OTHER | 1770534539 | 01 | NPI | OTHER | 1306897202 | 01 | NPI | OTHER | 1588676456 | 01 | NPI | OTHER | 3386406 | 01 | MEDICARE PTAN (S. STEFFEY) | OTHER | 4312365 | 01 | TN | BLUE CROSS BLUE SHIELD GROUP | OTHER |