Provider Demographics
NPI:1124426259
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KRUTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3423
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:423-431-4847
Mailing Address - Fax:423-431-3949
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:NISWONGER CHILDREN'S HOSPITAL ADMIN
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-4847
Practice Address - Fax:423-431-3949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-05
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ010765Medicaid
TNQ010765Medicaid