Healthcare Provider Details

I. General information

NPI: 1356405120
Provider Name (Legal Business Name): HOLSTON MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W STONE DR 1H
KINGSPORT TN
37660-3256
US

IV. Provider business mailing address

PO BOX 9
KINGSPORT TN
37662-0009
US

V. Phone/Fax

Practice location:
  • Phone: 423-392-6200
  • Fax: 423-392-6593
Mailing address:
  • Phone: 423-857-2066
  • Fax: 423-857-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

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