Basic Information
| Provider Information | |||||||||
| NPI: | 1699819003 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TAKOMA REGIONAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BALLAD HEALTH MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 BROOKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233430434 | ||||||||
| FaxNumber: | 4233430435 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 TUSCULUM BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377454279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237875000 | ||||||||
| FaxNumber: | 4237875009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2007 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRUTAK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4233023423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| 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 | 100020449 | 01 | TN | PREFERRED HEALTH | OTHER | 4147074 | 01 | TN | BLUE CROSS | OTHER | 3774303 | 01 | TN | JOHN DEERE | OTHER |