Basic Information
Provider Information | |||||||||
NPI: | 1053340158 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLMONT HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HANCOCK COUNTY HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 311 PRINCETON RD STE 1 | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376012026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237335000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1519 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | SNEEDVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 37869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237335000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2006 | ||||||||
LastUpdateDate: | 10/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KRUTAK | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
AuthorizedOfficialTelephone: | 4233023423 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X |   |   | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | A3786976 | 05 | TN |   | MEDICAID | 18472600 | 05 | TN |   | MEDICAID | 100049188 | 05 | TN |   | MEDICAID | 4098162 | 05 | TN |   | MEDICAID | 0441313 | 05 | TN |   | MEDICAID | 010246172 | 05 | VA |   | MEDICAID | 4098162 | 01 | TN | TN BLUE CROSS | OTHER | A3786976 | 01 | TN | UHC RIVER VALLEY | OTHER |