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NPI Code Detail

MEDICARE: WELLMONT MEDICAL ASSOCIATES, INC.

MEDICARE: WELLMONT MEDICAL ASSOCIATES, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1293D00000XPhysiological Laboratory

General Provider Information

NPI Number : 1740863968
Entity Type Code : Organization
Provider Name (Legal Business Name) : WELLMONT MEDICAL ASSOCIATES, INC.
Provider Business Mailing Address
First Line : 311 PRINCETON RD STE 1
Second Line :
City : JOHNSON CITY
State : TN
Zip : 37601-2080
Country : US
Telephone Number : 423-302-6239
Fax Number : 423-302-6248
Provider Business Practice Location Address
First Line : 301 MED TECH PKWY
Second Line :
City : JOHNSON CITY
State : TN
Zip : 37604-2630
Country : US
Telephone Number : 423-302-6239
Fax Number : 423-302-6248
Authorized Official
Title or Position : EVP/CFO
Name : MARY LYNN KRUTAK
Credential :
Telephone Number : 423-302-3423
Provider Enumeration Date : 05/05/2021
Last Update Date : 05/21/2021

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