Provider Demographics
NPI:1871952762
Name:FAMILY MEDICINE OF OUR MOUNTAINS PC
Entity type:Organization
Organization Name:FAMILY MEDICINE OF OUR MOUNTAINS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-791-0839
Mailing Address - Street 1:245 FORT CHISWELL RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:MAX MEADOWS
Mailing Address - State:VA
Mailing Address - Zip Code:24360-3986
Mailing Address - Country:US
Mailing Address - Phone:276-595-5300
Mailing Address - Fax:276-595-5850
Practice Address - Street 1:245 FORT CHISWELL RD
Practice Address - Street 2:SUITE D
Practice Address - City:MAX MEADOWS
Practice Address - State:VA
Practice Address - Zip Code:24360-3986
Practice Address - Country:US
Practice Address - Phone:276-595-5300
Practice Address - Fax:276-595-5850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-19
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1871952762Medicaid