Basic Information
| Provider Information | |||||||||
| NPI: | 1861857567 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAKOMA REGIONAL HOSPITAL, INC. | ||||||||
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| OtherOrganizationName: | BALLAD HEALTH MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W STONE DR STE 6A | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 MONARCH PT | ||||||||
| Address2: | |||||||||
| City: | GREENEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377454275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237986630 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2015 | ||||||||
| LastUpdateDate: | 02/20/2019 | ||||||||
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| AuthorizedOfficialLastName: | WILGOCKI | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4234315794 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TAKOMA REGIONAL HOSPITAL, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.