MEDICARE: MOUNTAIN STATES HEALTH ALLIANCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center		VA

General Provider Information

NPI Number	:	1609054733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN STATES HEALTH ALLIANCE

Provider Business Mailing Address
First Line	:	311 PRINCETON RD STE 1
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-2026
Country	:	US
Telephone Number	:	276-762-2300
Fax Number	:	276-762-0612

Provider Business Practice Location Address
First Line	:	16431 WISE STREET
Second Line	:
City	:	SAINT PAUL
State	:	VA
Zip	:	24283-3537
Country	:	US
Telephone Number	:	276-762-2300
Fax Number	:	276-762-0612

Authorized Official
Title or Position	:	EVP/CFO
Name	:	SHANE EDWIN HILTON
Credential	:
Telephone Number	:	423-302-3467

Provider Enumeration Date	:	01/31/2008
Last Update Date	:	04/16/2024

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Directions to “MOUNTAIN STATES HEALTH ALLIANCE ” Practice Location

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