NPIMap

Organization Active NPI

Mountain States Health Alliance

  • Pediatrics Physician
  • Johnson City, TN
National Provider Identifier
1124426259
Registry record updated Feb 26, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 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
Last updated
Feb 26, 2018By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 26, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

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

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Nurse Practitioner 363LP0200X
Pediatrics Physician 208000000X Primary
Pediatric Critical Care Medicine Physician 2080P0203X

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 1

IdentifierTypeStateIssuer
Q010765MedicaidTN

National Provider Directory

National Provider Directory

Member of 1

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

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1417737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1519603200000",
    "number": "1124426259",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "311 PRINCETON RD STE 1",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376012026",
            "telephone_number": "423-431-4847",
            "fax_number": "423-431-3949"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 N STATE OF FRANKLIN RD",
            "address_2": "NISWONGER CHILDREN'S HOSPITAL ADMIN",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376046035",
            "telephone_number": "423-431-4847",
            "fax_number": "423-431-3949"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN STATES HEALTH ALLIANCE",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-05",
        "last_updated": "2018-02-26",
        "status": "A",
        "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"
    },
    "taxonomies": [
        {
            "code": "363LP0200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2080P0203X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Pediatric Critical Care Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q010765",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Johnson City, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 26, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.