Basic Information
| Provider Information | |||||||||
| NPI: | 1801826912 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLMONT HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LONESOME PINE HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 PRINCETON RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376012026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765233111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1990 HOLTON AVE E | ||||||||
| Address2: | |||||||||
| City: | BIG STONE GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765233111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| 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 | 000000064909 | 01 | KY | KY BLUE CROSS | OTHER | 0166098400 | 05 | KY | MEDICAID | A2421917 | 01 | TN | UHC RIVER VALLEY | OTHER | 004901142 | 05 | VA | MEDICAID | 281670 | 01 | VA | ANTHEM | OTHER | A2421917 | 05 | TN | MEDICAID | 033385600 | 01 | TN | BLACK LUNG | OTHER | 166592402 | 01 | TN | DEPT LABOR WORK COMP TN | OTHER | 9810037000 | 05 | WV | MEDICAID | 3072953 | 05 | TN | MEDICAID |