Basic Information
| Provider Information | |||||||||
| NPI: | 1285685727 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DICKENSON COMMUNITY 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: | 2769260300 | ||||||||
| FaxNumber: | 2769260329 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | CLINTWOOD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242286786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2769260300 | ||||||||
| FaxNumber: | 2769260329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| 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 | 282NC0060X | H1918 | VA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 102340 | 01 | VA | ANTHEM BLUE CROSS | OTHER | 01601087 | 05 | KY | MEDICAID | 010038146 | 05 | VA | MEDICAID | A24228 00 | 01 | JOHN DEERE | OTHER |