Provider Demographics
NPI:1104059344
Name:OVER THE MOUNTAIN INTERNAL MEDICINE LLC
Entity type:Organization
Organization Name:OVER THE MOUNTAIN INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-877-5400
Mailing Address - Street 1:2018 BROOKWOOD MEDICAL CTR DR
Mailing Address - Street 2:STE 315
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-6898
Mailing Address - Country:US
Mailing Address - Phone:205-877-5400
Mailing Address - Fax:205-877-5040
Practice Address - Street 1:2018 BROOKWOOD MEDICAL CTR DR
Practice Address - Street 2:STE 315
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-6898
Practice Address - Country:US
Practice Address - Phone:205-877-5400
Practice Address - Fax:205-877-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14251207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALE42218Medicare UPIN