Provider Demographics
NPI:1174808216
Name:WELLMONT MEDICAL ASSOCIATES INC
Entity type:Organization
Organization Name:WELLMONT MEDICAL ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-6565
Mailing Address - Street 1:2020 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4633
Mailing Address - Country:US
Mailing Address - Phone:423-343-0434
Mailing Address - Fax:423-343-0435
Practice Address - Street 1:323 CLOVERLEAF SQ
Practice Address - Street 2:#1
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-2760
Practice Address - Country:US
Practice Address - Phone:276-523-6715
Practice Address - Fax:276-523-6719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB288Medicare PIN