MEDICARE: WELLMONT PHYSICIAN SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site		TN

General Provider Information

NPI Number	:	1770753444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLMONT PHYSICIAN SERVICES INC

Provider Business Mailing Address
First Line	:	999 EXECUTIVE PARK BLVD
Second Line	:	SUITE 201
City	:	KINGSPORT
State	:	TN
Zip	:	37660-4632
Country	:	US
Telephone Number	:	423-224-3250
Fax Number	:	423-224-3258

Provider Business Practice Location Address
First Line	:	111 W STONE DR
Second Line	:	SUITE 300
City	:	KINGSPORT
State	:	TN
Zip	:	37660-6027
Country	:	US
Telephone Number	:	423-224-3150
Fax Number	:	423-224-3169

Authorized Official
Title or Position	:	BILLING ADMINISTRATOR
Name	:	CINDY M LOCKE
Credential	:	CPC, CCS-P, CPC-I
Telephone Number	:	423-224-3250

Provider Enumeration Date	:	03/10/2008
Last Update Date	:	03/04/2010

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Directions to “WELLMONT PHYSICIAN SERVICES INC ” Practice Location

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