Provider Demographics
NPI:1073782900
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:RUSSELL COUNTY MEDICAL CENTER ANESTHESIOLOGY DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:EICHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-431-1017
Mailing Address - Street 1:58 CARROLL STREET
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-4510
Mailing Address - Country:US
Mailing Address - Phone:276-883-8000
Mailing Address - Fax:
Practice Address - Street 1:58 CARROLL STREET
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-4510
Practice Address - Country:US
Practice Address - Phone:276-883-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1892207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty