1487690400 NPI number — WELLMONT HEALTH SYSTEM

Table of content: (NPI 1487690400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487690400 NPI number — WELLMONT HEALTH SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLMONT HEALTH SYSTEM
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:
HOLSTON VALLEY MEDICAL CENTER
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:
1487690400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 PRINCETON RD STE 1
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:
423-224-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 W RAVINE RD
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-224-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HILTON
Authorized Official First Name:
SHANE
Authorized Official Middle Name:
EDWIN
Authorized Official Title or Position:
EVP/CFO
Authorized Official Telephone Number:
423-302-3467

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0039640 . This is a "UMWA OUT-PATIENT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 240866 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1000805 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4400017 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6530375 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0039632 . This is a "UMWA IN-PATIENT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 092263300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166592401 . This is a "POSTAL WORKERS DEPT OF LA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 1741825 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004400178 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0169767000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: A3766001 . This is a "UHC RIVER VALLEY" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 036101100 . This is a "BLACK LUNG" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 0440017 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100020304 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0162200000 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000805 . This is a "TN BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: A3766001 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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