Provider Demographics
NPI:1962432088
Name:WELLMONT HEALTH SYSTEM
Entity type:Organization
Organization Name:WELLMONT HEALTH SYSTEM
Other - Org Name:<UNAVAIL>
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:423-844-5252
Mailing Address - Fax:423-844-6379
Practice Address - Street 1:280 STEELES RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-844-5252
Practice Address - Fax:423-844-6379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44-1558Medicare ID - Type Unspecified