Basic Information
| Provider Information | |||||||||
| NPI: | 1386834547 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNSTON MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | HOSPITALIST OF JOHNSTON MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762584050 | ||||||||
| FaxNumber: | 2762584056 | ||||||||
| Practice Location | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762584050 | ||||||||
| FaxNumber: | 2762584056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | JETER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2762582830 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JOHNSTON MEMORIAL HOSPITAL, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 0101239640 | VA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 0101238469 | VA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 0101237946 | VA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 363AM0700X | 0110002132 | VA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 208M00000X | 0101221395 | VA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | CB9307 | 01 | VA | RR MEDICARE | OTHER | 618072300 | 01 | VA | DOL/ENERGY & FECA | OTHER | 1525980 | 05 | TN | MEDICAID | 032157100 | 01 | VA | BLACK LUNG | OTHER | 1104812684 | 05 | VA | MEDICAID |