Basic Information
| Provider Information | |||||||||
| NPI: | 1104812684 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHNSTON MEMORIAL HOSPITAL, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 PRINCETON RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376012026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762581000 | ||||||||
| FaxNumber: | 2762582805 | ||||||||
| Practice Location | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762581000 | ||||||||
| FaxNumber: | 2762582805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | KRUTAK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4233023423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | H1864 | VA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 007658 | 01 | VA | ANTHEM BLUE CROSS | OTHER | 1104812684 | 05 | VA | MEDICAID | 142849 | 01 | VA | BLUE CROSS REF. LAB | OTHER | CB9307 | 01 | VA | RR MEDICARE | OTHER |