Basic Information
| Provider Information | |||||||||
| NPI: | 1215584750 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST MOUNTAIN HEALTH PHYSICIANS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VALLEY HEALTH FAMILY MEDICINE HEDGESVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 CAMPUS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5405365100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3790 HEDGESVILLE RD STE H | ||||||||
| Address2: | |||||||||
| City: | HEDGESVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 254276704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047547160 | ||||||||
| FaxNumber: | 3047547244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2019 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
| AuthorizedOfficialMiddleName: | NEVADA | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5405360103 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST MOUNTAIN HEALTH PHYSICIANS, INC. | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.