Healthcare Provider Details

I. General information

NPI: 1366560161
Provider Name (Legal Business Name): WELLMONT PHYSICIAN SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CLOVERLEAF SQ SUITE F1
BIG STONE GAP VA
24219-2758
US

IV. Provider business mailing address

999 EXECUTIVE PARK BLVD SUITE 201
KINGSPORT TN
37660-4632
US

V. Phone/Fax

Practice location:
  • Phone: 276-523-6175
  • Fax: 276-523-6719
Mailing address:
  • Phone: 423-224-3250
  • Fax: 423-224-3258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

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