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General NPI Number Information
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NPI Number | 1619164365
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Entity Type | Organization
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Legal Business Name | MOUNTAINEER GASTROENTEROLOGY INC
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Dates
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Enumeration Date | 09/26/2007
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Last Update Date | 09/21/2010
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Provider Practice Location Address
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Address Line | 1100 CEDAR VALLEY DR,
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City | CEDAR BLUFF
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State | VA
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Zip | 24609
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Country | US
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Telephone | 276-596-9980
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Fax | 276-596-9981
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Provider Business Mailing Address
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Address Line | 4035 COLLEGE AVENUE #102
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City | BLUEFIELD
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State | VA
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Zip | 24605
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Country | US
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Telephone | 276-596-9980
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Fax | 276-596-9981
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | THOMAS B CORTELLESI
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Credential | DO
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Telephone | 276-596-9980
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 1732
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 0102037199
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License Number State | VA
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