Basic Information
| Provider Information | |||||||||
| NPI: | 1487690400 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLMONT HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | HOLSTON VALLEY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 311 PRINCETON RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376012026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232244000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 130 W RAVINE RD | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232244000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRUTAK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4233023423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 036101100 | 01 | TN | BLACK LUNG | OTHER | 0440017 | 05 | TN | MEDICAID | A3766001 | 05 | TN | MEDICAID | 004400178 | 05 | VA | MEDICAID | 092263300 | 05 | FL | MEDICAID | 100020304 | 05 | TN | MEDICAID | 1000805 | 05 | TN | MEDICAID | 0162200000 | 05 | KY | MEDICAID | 0169767000 | 05 | WV | MEDICAID | 166592401 | 01 | TN | POSTAL WORKERS DEPT OF LA | OTHER | 4400017 | 05 | NC | MEDICAID | 1000805 | 01 | TN | TN BLUE CROSS | OTHER | 0039640 | 01 | TN | UMWA OUT-PATIENT | OTHER | 1741825 | 05 | LA | MEDICAID | 6530375 | 01 | TN | AETNA | OTHER | 240866 | 01 | VA | ANTHEM BLUE CROSS | OTHER | A3766001 | 01 | TN | UHC RIVER VALLEY | OTHER | 0039632 | 01 | TN | UMWA IN-PATIENT | OTHER |