Basic Information
| Provider Information | |||||||||
| NPI: | 1437203155 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COPPER BASIN COMMUNITY HOSPITAL INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ED COPPER BASIN MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 144 MEDICAL CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | COPPERHILL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373170144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234965511 | ||||||||
| FaxNumber: | 4234969311 | ||||||||
| Practice Location | |||||||||
| Address1: | 144 MEDICAL CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | COPPERHILL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373170144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234965511 | ||||||||
| FaxNumber: | 4234969311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 05/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4234965511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0000000094 | 01 | TN | HEALTH CARE FACILITIES | OTHER | 300040218A | 05 | GA | MEDICAID |