Basic Information
| Provider Information | |||||||||
| NPI: | 1972606465 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN STATES HEALTH ALLIANCE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JOHNSON CITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 09/07/2006 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRUTAK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4233023423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 0000000121 | TN | N | Hospital Units | Psychiatric Unit | 282N00000X | 0000000121 | TN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0440063 | 05 | TN | MEDICAID | 1749478 | 05 | LA | MEDICAID | 01675483 | 05 | NY | MEDICAID | 091618800 | 05 | FL | MEDICAID | A3760501 | 01 | JOHN DEERE | OTHER | 070026 | 01 | CIGNA | OTHER | 42332 | 05 | SC | MEDICAID | 4688190 | 05 | MI | MEDICAID | 000262138X | 05 | GA | MEDICAID | 01620418 | 05 | KY | MEDICAID | 4400063 | 05 | NC | MEDICAID | 463496 | 05 | SC | MEDICAID | 030283600 | 01 | BLACK LUNG | OTHER | 05431336 | 05 | MS | MEDICAID | 4699882 | 05 | MI | MEDICAID | 9802156000 | 05 | WV | MEDICAID | JOH0063N | 05 | AL | MEDICAID | 0579913 | 05 | OH | MEDICAID |