Healthcare Provider Details

I. General information

NPI: 1841711512
Provider Name (Legal Business Name): EAST MOUNTAIN HEALTH PHYSICIANS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OAK LEE DRIVE
RANSON WV
25438
US

IV. Provider business mailing address

PO BOX 37818
BALTIMORE MD
21297-7818
US

V. Phone/Fax

Practice location:
  • Phone: 304-930-0001
  • Fax: 681-252-1843
Mailing address:
  • Phone: 540-536-3386
  • Fax: 540-536-3263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number StateWV

VIII. Authorized Official

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