Healthcare Provider Details

I. General information

NPI: 1205554664
Provider Name (Legal Business Name): HOLSTON MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 PEOPLES STREET CONDO 300
JOHNSON CITY TN
37604
US

IV. Provider business mailing address

PO BOX 9
KINGSPORT TN
37662-0009
US

V. Phone/Fax

Practice location:
  • Phone: 423-461-2100
  • Fax:
Mailing address:
  • Phone: 423-857-2066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: AUDRA LAWSON
Title or Position: CONTRACT ANALYST
Credential:
Phone: 423-857-2066