Provider Demographics
NPI:1114033628
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:HILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3467
Mailing Address - Street 1:311 PRINCETON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2026
Mailing Address - Country:US
Mailing Address - Phone:423-302-1100
Mailing Address - Fax:423-302-1129
Practice Address - Street 1:300 MED TECH PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2277
Practice Address - Country:US
Practice Address - Phone:423-302-1100
Practice Address - Fax:423-302-1129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000123282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0100675Medicaid
VA004401841Medicaid
030508600OtherBLACK LUNG
0700329OtherCIGNA
MS08001831Medicaid
FL091618800Medicaid
1000381OtherBLUE CROSS
A3760127OtherJOHN DEERE
OH0657632Medicaid
NC4400184Medicaid
MI4703653Medicaid
TN0440184Medicaid
100020098OtherPHP
437728OtherANTHEM
OH0657632Medicaid