Basic Information
| Provider Information | |||||||||
| NPI: | 1962915652 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN STATES HEALTH ALLIANCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | JOHNSON CITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 PRINCETON RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376012026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234316111 | ||||||||
| FaxNumber: | 4234313549 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N STATE OF FRANKLIN RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234316111 | ||||||||
| FaxNumber: | 4234313549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2017 | ||||||||
| LastUpdateDate: | 03/14/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRUTAK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4233023423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNTAIN STATES HEALTH ALLIANCE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
No ID Information.