1023129376 NPI number — MOUNTAIN STATES HEALTH ALLIANCE

Table of content: (NPI 1023129376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023129376 NPI number — MOUNTAIN STATES HEALTH ALLIANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN STATES HEALTH ALLIANCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JOHNSON CITY SPECIALTY HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023129376
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 E WATAUGA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37601-4629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-926-1111
Provider Business Mailing Address Fax Number:
423-979-6163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 E WATAUGA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37601-4629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-926-1111
Provider Business Practice Location Address Fax Number:
423-979-6163
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EICHORN
Authorized Official First Name:
MARVIN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
SVP/CFO
Authorized Official Telephone Number:
423-431-6111

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  0000000122 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4400105 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: A3760124 . This is a "JOHN DEERE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100020074 . This is a "PHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 091618800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 437727 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 004401051 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01600964 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000373 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0440105 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0700245 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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