1306957659 NPI number — MOUNTAIN STATES HEALTH ALLIANCE

Table of content: (NPI 1306957659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306957659 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:
Provider Other Organization Name Type Code:
6
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:
1306957659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
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:
423-727-3250
Provider Business Mailing Address Fax Number:
423-727-9170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1987A S SHADY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37683-2021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-727-3250
Provider Business Practice Location Address Fax Number:
423-727-9170
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILGOCKI
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
CORP DIRECTOR REIMBURSEMENT
Authorized Official Telephone Number:
423-431-5794

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  0000000130 , 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)





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