Provider Demographics
NPI:1992813240
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:423-857-7000
Mailing Address - Fax:423-857-7078
Practice Address - Street 1:2000 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4627
Practice Address - Country:US
Practice Address - Phone:423-857-7000
Practice Address - Fax:423-857-7078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000134282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000363855XMedicaid
KY01600113Medicaid
1000807OtherBLUE CROSS
17505000OtherMAGELLAN
VA004401760Medicaid
MS00672239Medicaid
TN0440176Medicaid
3457347OtherCIGNA
OH0938025Medicaid
A3766020OtherJOHN DEERE
FL091618800Medicaid
NC4400176Medicaid
MI4699873Medicaid
SC000127730Medicaid
030138700OtherBLACK LUNG
226529OtherANTHEM
MI4699882Medicaid
A3766020OtherJOHN DEERE