1558949420 NPI number — WELLMONT HEALTH SYSTEM

Table of content: KRISTA BROWN (NPI 1710469077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558949420 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:
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:
1558949420
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 PROFESSIONAL PARK DR STE 15
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:
37604-6584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-434-7443
Provider Business Mailing Address Fax Number:
423-302-3537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
671 HIGHWAY 58 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24273-3007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-439-1860
Provider Business Practice Location Address Fax Number:
423-610-3365
Provider Enumeration Date:
03/31/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KRUTAK
Authorized Official First Name:
MARY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
EVP/CFO
Authorized Official Telephone Number:
423-302-3423

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1801826912 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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