Basic Information
| Provider Information | |||||||||
| NPI: | 1295701217 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNICOI COUNTY MEMORIAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UNICOI CTY MEMORIAL HOSPITAL CTY NURSING HOME CTY HOME HEALTH AGENCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GREENWAY CIRCLE | ||||||||
| Address2: | |||||||||
| City: | ERWIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237433141 | ||||||||
| FaxNumber: | 4237431244 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 GREENWAY CIRCLE | ||||||||
| Address2: | |||||||||
| City: | ERWIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237433141 | ||||||||
| FaxNumber: | 4237431244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATE | ||||||||
| AuthorizedOfficialFirstName: | JIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4237433141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0000000119 | TN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0440001 | 05 | TN | MEDICAID |