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
58 CARROLL STREET, LEBANON, VA 24266-4510
(276) 883-8000
(276) 883-8250
Mailing address
311 PRINCETON RD STE 1, JOHNSON CITY, TN 37601-2026
(276) 883-8000
(276) 883-8250
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
H1892
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1922003730
—
VA
Enumeration date
02/13/2008
Last updated
03/14/2018
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