Healthcare Provider Details

I. General information

NPI: 1366504789
Provider Name (Legal Business Name): MOUNTAIN MEDICAL SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 ADAMS DR
DEMOREST GA
30535-4501
US

IV. Provider business mailing address

PO BOX 909
CLARKESVILLE GA
30523-0016
US

V. Phone/Fax

Practice location:
  • Phone: 706-754-5191
  • Fax: 706-754-5191
Mailing address:
  • Phone: 706-754-5191
  • Fax: 706-754-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN124242
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number26375
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number26375
License Number StateGA

VIII. Authorized Official

Name: SONYA D HIX
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 706-754-5191