1417050980 NPI number — MOUNTAIN STATES HEALTH ALLIANCE

Table of content: (NPI 1417050980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417050980 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:
INDIAN PATH PAVILION
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:
1417050980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 PRINCETON RD
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:
37601-2026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-431-1941
Provider Business Mailing Address Fax Number:
423-431-1244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 PAVILION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-857-5500
Provider Business Practice Location Address Fax Number:
423-857-7078
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KRUTAK
Authorized Official First Name:
MARY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
SVP/CFO
Authorized Official Telephone Number:
423-431-6111

Provider Taxonomy Codes

  • Taxonomy code: 273R00000X , with the licence number:  0000000134 , 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: 4699873 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000363855X , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004401760 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01600113 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 091618800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0938025 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17505000 . This is a "MEGELLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000127730 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00672239 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4400176 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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