Healthcare Provider Details

I. General information

NPI: 1033681150
Provider Name (Legal Business Name): EAST MOUNTAIN HEALTH PHYSICIANS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2018
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4803 GERRARDSTOWN RD
INWOOD WV
25428-3450
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 200
WINCHESTER VA
22601-2889
US

V. Phone/Fax

Practice location:
  • Phone: 304-821-9011
  • Fax: 304-821-9012
Mailing address:
  • Phone: 540-536-5100
  • Fax: 540-536-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
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