Provider Demographics
NPI:1043339385
Name:WELLMONT PHYSICIAN SERVICES INC
Entity type:Organization
Organization Name:WELLMONT PHYSICIAN SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:CPC CCS-P
Authorized Official - Phone:423-224-3250
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:1980 HOLTON AVE E
Practice Address - Street 2:SUITE 301
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3366
Practice Address - Country:US
Practice Address - Phone:276-523-0390
Practice Address - Fax:423-523-5514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65942757Medicaid
VA=========006OtherCHAMPUS
VAC09208Medicare PIN
KY65942757Medicaid