Healthcare Provider Details

I. General information

NPI: 1972771236
Provider Name (Legal Business Name): MOUNTAIN STATES HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 CARROLL STREET
LEBANON VA
24266
US

IV. Provider business mailing address

PO BOX 3600
LEBANON VA
24266-0200
US

V. Phone/Fax

Practice location:
  • Phone: 276-883-8471
  • Fax: 276-883-8475
Mailing address:
  • Phone: 276-883-8471
  • Fax: 276-883-8475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: C STEVEN KILGORE VI
Title or Position: PRESIDENT
Credential:
Phone: 423-915-5185