Healthcare Provider Details

I. General information

NPI: 1861857567
Provider Name (Legal Business Name): TAKOMA REGIONAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 MONARCH PT
GREENEVILLE TN
37745-4275
US

IV. Provider business mailing address

105 W STONE DR STE 6A
KINGSPORT TN
37660-3256
US

V. Phone/Fax

Practice location:
  • Phone: 423-798-6630
  • Fax:
Mailing address:
  • Phone: 423-408-7220
  • Fax: 423-408-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY LEE WILGOCKI
Title or Position: VP REIMBURSEMENT
Credential:
Phone: 423-431-5794