Basic Information
| Provider Information | |||||||||
| NPI: | 1427201813 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA MEDICAL CENTER MOUNTAIN HOME, TN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1ST STREET, BLDG 204 | ||||||||
| Address2: | JAMES H. QUILLEN VA MEDICAL CENTER EMERGENCY DEPT | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1ST STREET BLDG 204 | ||||||||
| Address2: | JAMES H. QUILLEN VA MEDICAL CENTER EMERGENCY DEPT | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376844000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239261171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2008 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | TESTERMAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | FRANK | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 4239261171 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | TNPA036 | TN | Y | Hospitals | General Acute Care Hospital |
No ID Information.