1013391507 NPI number — MOUNTAIN STATES HEALTH ALLIANCE

Table of content: (NPI 1013391507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013391507 NPI number — MOUNTAIN STATES HEALTH ALLIANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN STATES HEALTH ALLIANCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013391507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 PRINCETON RD STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37601-2026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-431-6816
Provider Business Mailing Address Fax Number:
423-743-1244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 ONEEGA LN
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
ERWIN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37650-2197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-431-6816
Provider Business Practice Location Address Fax Number:
423-743-1244
Provider Enumeration Date:
07/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
KRUTAK
Authorized Official First Name:
MARY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
EVP/CFO
Authorized Official Telephone Number:
423-302-3423

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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