NPIMap

Organization Active NPI

Mountain States Health Alliance

Doing business as Indian Path Pavilion

  • Psychiatric Hospital Unit
  • Kingsport, TN
National Provider Identifier
1417050980
Registry record updated Oct 15, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric Hospital UnitTaxonomy code 273R00000X
License
0000000134 Issued in TN
Legal business name
MOUNTAIN STATES HEALTH ALLIANCE
Doing business as
Indian Path Pavilion
Practice address
2300 Pavilion Dr
Kingsport, TN 37660-4622
Phone
(423) 857-5500
Fax
(423) 857-7078
NPI assigned
Sep 7, 2006
Last updated
Oct 15, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 15, 2015

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

Authorized official

Name
Mrs. Mary L Krutak
Title
SVP/Cfo
Phone
(423) 431-6111

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatric Hospital Unit 273R00000X 0000000134 TN Primary

Addresses

Primary practice location

2300 Pavilion Dr
Kingsport, TN 37660-4622

Mailing address

311 Princeton Rd
Johnson City, TN 37601-2026
Phone (423) 431-1941

Other identifiers 10

IdentifierTypeStateIssuer
000363855XMedicaidGA
004401760MedicaidVA
0938025MedicaidOH
17505000OtherMEGELLAN
4400176MedicaidNC
091618800MedicaidFL
00672239MedicaidMS
000127730MedicaidSC
01600113MedicaidKY
4699873MedicaidMI

Other names 1

  • Indian Path Pavilion Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040415001070 TN Part B Supplier - Clinic/Group Practice 6002726718 Receives reassigned benefits from 18 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Johnson City, TN; Mountain City, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1417050980. Details of each certification follow.

Hospital certification: CCN 444012

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
(CLOSED) INDIAN PATH PAVILION
Certification status
Terminated Voluntary: merger or closure, Oct 1, 1996
Provider type (POS)
Hospital – Psychiatric
Participating since
Jun 7, 1984
Last certification
Apr 6, 1995
Beds
61
Ownership / control type
Private (for profit)
Facility address
2300 Pavilion Drive
Kingsport, TN 37660

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 26

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 26

NPI Registry JSON

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

{
    "created_epoch": "1157587200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1444867200000",
    "number": "1417050980",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "311 PRINCETON RD",
            "city": "JOHNSON CITY",
            "state": "TN",
            "postal_code": "376012026",
            "telephone_number": "423-431-1941",
            "fax_number": "423-431-1244"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2300 PAVILION DR",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "376604622",
            "telephone_number": "423-857-5500",
            "fax_number": "423-857-7078"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN STATES HEALTH ALLIANCE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-07",
        "last_updated": "2015-10-15",
        "status": "A",
        "authorized_official_last_name": "KRUTAK",
        "authorized_official_first_name": "MARY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "SVP/CFO",
        "authorized_official_telephone_number": "423-431-6111",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": "TN",
            "license": "0000000134",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000363855X",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004401760",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0938025",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEGELLAN",
            "identifier": "17505000",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4400176",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "091618800",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00672239",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000127730",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01600113",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4699873",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Indian Path Pavilion",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kingsport, TN

Sources for this page

Verify at the official NPI Registry.