=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093580466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOUNTAIN STATES HEALTH ALLIANCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2023
-----------------------------------------------------
Last Update Date | 11/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 PROFESSIONAL PARK DR STE 21
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-6909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-232-6900
-----------------------------------------------------
Fax | 423-232-6903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1021 W OAKLAND AVE STE 310
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-2192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-302-6565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENROLLMENT SUPERVISOR
-----------------------------------------------------
Name | PATRICIA TARTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-302-6565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------