Organization
MOUNTAIN STATES HEALTH ALLIANCE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARY LYNN KRUTAK (EVP/CFO)
(423) 302-3423
Entity
Organization
Contact information
Practice address
400 N STATE OF FRANKLIN RD, NISWONGER CHILDREN'S HOSPITAL ADMIN, JOHNSON CITY, TN 37604-6035
(423) 431-4847
(423) 431-3949
Mailing address
311 PRINCETON RD STE 1, JOHNSON CITY, TN 37601-2026
(423) 431-4847
(423) 431-3949
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
—
—
2080P0203X
Pediatric Critical Care Medicine Physician
—
—
363LP0200X
Pediatric Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
Q010765
—
TN
Enumeration date
12/05/2014
Last updated
02/26/2018
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