Healthcare Provider Details

I. General information

NPI: 1215584750
Provider Name (Legal Business Name): EAST MOUNTAIN HEALTH PHYSICIANS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 HEDGESVILLE RD STE H
HEDGESVILLE WV
25427-6704
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 100
WINCHESTER VA
22601-2888
US

V. Phone/Fax

Practice location:
  • Phone: 304-754-7160
  • Fax: 304-754-7244
Mailing address:
  • Phone: 540-536-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RENEE NEVADA JOHNSON
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 540-536-0103