Basic Information
| Provider Information | |||||||||
| NPI: | 1871761726 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN STATES HEALTH ALLIANCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 PRINCETON RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376012026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2768838000 | ||||||||
| FaxNumber: | 2768838250 | ||||||||
| Practice Location | |||||||||
| Address1: | 58 CARROLL STREET | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242664510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2768838000 | ||||||||
| FaxNumber: | 2768838250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2008 | ||||||||
| LastUpdateDate: | 03/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | KRUTAK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4233023423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | H1892 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1922003730 | 05 | VA | MEDICAID |