1295193183 NPI number — WELLMONT MEDICAL ASSOCIATES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295193183 NPI number — WELLMONT MEDICAL ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLMONT MEDICAL ASSOCIATES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295193183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
509 MED TECH PKWY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37604-2579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-952-2111
Provider Business Mailing Address Fax Number:
423-952-2175

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
410 STAGECOACH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24201-8359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-466-0480
Provider Business Practice Location Address Fax Number:
276-669-8583
Provider Enumeration Date:
02/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGAN
Authorized Official First Name:
TODD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
WHS SR VP FINANCE
Authorized Official Telephone Number:
423-230-8512

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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