Provider Demographics
NPI:1104823087
Name:EXTENDED CARE PHYSICIANS - MOUNTAIN, PA
Entity type:Organization
Organization Name:EXTENDED CARE PHYSICIANS - MOUNTAIN, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEESON-WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-277-4810
Mailing Address - Street 1:PO BOX 890291
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 SOUTHSIDE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4160
Practice Address - Country:US
Practice Address - Phone:828-277-4810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QG0300X, 2084P0805X, 363LF0000X, 363LG0600X, 207Q00000X, 207R00000X, 208D00000X, 363L00000X, 363LP0808X, 363A00000X
NC86999363LA2200X, 363LA2100X
NC200201376207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC011JKOtherBCBSNC
NC89011JKMedicaid
NC56162OtherMEDCOST
NCCG9205OtherRAILROAD MEDICARE
NC2344379Medicare PIN