Healthcare Provider Details

I. General information

NPI: 1124426259
Provider Name (Legal Business Name): MOUNTAIN STATES HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N STATE OF FRANKLIN RD NISWONGER CHILDREN'S HOSPITAL ADMIN
JOHNSON CITY TN
37604-6035
US

IV. Provider business mailing address

311 PRINCETON RD STE 1
JOHNSON CITY TN
37601-2026
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-4847
  • Fax: 423-431-3949
Mailing address:
  • Phone: 423-431-4847
  • Fax: 423-431-3949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARY LYNN KRUTAK
Title or Position: EVP/CFO
Credential:
Phone: 423-302-3423