Basic Information
| Provider Information | |||||||||
| NPI: | 1851419659 | ||||||||
| 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: | 1980 HOLTON AVE E | ||||||||
| Address2: | |||||||||
| City: | BIG STONE GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242193366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765238741 | ||||||||
| FaxNumber: | 2765238745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 04/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOCKE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4232243250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC CCS-P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 65931099 | 05 | KY | MEDICAID | 65942229 | 05 | KY | MEDICAID | 1527279 | 01 | VA | UMWA | OTHER | 023305000 | 01 | VA | FEDERAL BLACK LUNG | OTHER |