1609856590 NPI number — MOUNTAIN MEDICAL ARTS PLLC

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 1609856590 NPI number — MOUNTAIN MEDICAL ARTS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN MEDICAL ARTS PLLC
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:
1609856590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURNSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28714-1240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-678-9352
Provider Business Mailing Address Fax Number:
828-682-7866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURNSVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28714-2929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-678-9352
Provider Business Practice Location Address Fax Number:
828-682-7866
Provider Enumeration Date:
01/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROTHE
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
828-678-9352

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  NC200301048 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00252272 . This is a "PERSONAL MEDICARE #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: NC200301048 . This is a "STATE LICENCE #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89135R4 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135R4 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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