Healthcare Provider Details

I. General information

NPI: 1942482849
Provider Name (Legal Business Name): WELLMONT PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 09/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W RUSSELL ST
ELKHORN CITY KY
41522-7071
US

IV. Provider business mailing address

PO BOX 37024
BALTIMORE MD
21297-3024
US

V. Phone/Fax

Practice location:
  • Phone: 606-754-4158
  • Fax: 606-754-5452
Mailing address:
  • Phone: 423-224-3250
  • Fax: 423-224-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateKY

VIII. Authorized Official

Name: CINDY M LOCKE SR.
Title or Position: BILLING ADMINISTRATOR
Credential: CPC, CCS-P
Phone: 423-224-3250