Provider Demographics
NPI:1194771212
Name:LONESOME PINE ORTHOPAEDICS, PLC
Entity type:Organization
Organization Name:LONESOME PINE ORTHOPAEDICS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-679-1006
Mailing Address - Street 1:PO BOX 857
Mailing Address - Street 2:
Mailing Address - City:BIG STONE GAP
Mailing Address - State:VA
Mailing Address - Zip Code:24219-0857
Mailing Address - Country:US
Mailing Address - Phone:276-523-1006
Mailing Address - Fax:276-523-5293
Practice Address - Street 1:767 WOOD AVE E
Practice Address - Street 2:
Practice Address - City:BIG STONE GAP
Practice Address - State:VA
Practice Address - Zip Code:24219-3023
Practice Address - Country:US
Practice Address - Phone:276-523-1006
Practice Address - Fax:276-523-5293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65943912Medicaid
KY65943912Medicaid