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Mountain States Health Alliance

Organization Active NPI Pediatrics Physician · Johnson City, TN

NPI 1124426259 · NPPES record last updated Feb 26, 2018

Key facts

NPI
1124426259
Entity type
Organization (NPI type 2)
Primary specialty
Pediatrics Physician 208000000X
Legal business name
MOUNTAIN STATES HEALTH ALLIANCE
Practice address
400 N State of Franklin Rd
Niswonger Children'S Hospital Admin
Johnson City, TN 37604-6035
Phone
(423) 431-4847
Fax
(423) 431-3949
NPI assigned
Dec 5, 2014
Organization subpart
No

Authorized official

Name
Mary Lynn Krutak
Title
Evp/Cfo
Phone
(423) 302-3423

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

National Provider Directory

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 208000000X Yes
Pediatric Critical Care Medicine Physician
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 2080P0203X
Pediatric Nurse Practitioner
Group: 193400000X MULTIPLE SINGLE SPECIALTY GROUP		 363LP0200X

Addresses

Primary practice location

400 N State of Franklin Rd
Niswonger Children'S Hospital Admin
Johnson City, TN 37604-6035

Mailing address

311 Princeton Rd Ste 1
Johnson City, TN 37601-2026
Phone (423) 431-4847

Other identifiers

IdentifierTypeStateIssuer
Q010765MedicaidTN

Other providers in Johnson City, TN

All providers in Johnson City, TN · Pediatrics Physician in Tennessee

Sources for this page

Verify at the official NPI Registry.