1356638076 NPI number — DR. BRIAN KERMIT STILTNER D.O.

Table of content: KATHERINE WILLIAMS LCSW (NPI 1720816804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356638076 NPI number — DR. BRIAN KERMIT STILTNER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STILTNER
Provider First Name:
BRIAN
Provider Middle Name:
KERMIT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1356638076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 W OAKLAND AVE STE 310
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:
37604-2192
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-302-6565
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16000 JOHNSTON MEMORIAL DR
Provider Second Line Business Practice Location Address:
FOURTH FLOOR
Provider Business Practice Location Address City Name:
ABINGDON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24211-7664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-258-4050
Provider Business Practice Location Address Fax Number:
276-258-4056
Provider Enumeration Date:
07/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , with the licence number:  0102203297 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 0102203297 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1356638076 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q014857 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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