Provider Demographics
NPI:1104830405
Name:HIGHLANDS NEUROSURGERY PC
Entity Type:Organization
Organization Name:HIGHLANDS NEUROSURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:KISTNER
Authorized Official - Last Name:FLETCHER-HELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-844-5412
Mailing Address - Street 1:1 MEDICAL PARK BLVD STE 400E
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7431
Mailing Address - Country:US
Mailing Address - Phone:423-844-5400
Mailing Address - Fax:423-844-5434
Practice Address - Street 1:1 MEDICAL PARK BLVD STE 400E
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7431
Practice Address - Country:US
Practice Address - Phone:423-844-5400
Practice Address - Fax:423-844-5434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3389587Medicaid
WV3810004833Medicaid
VA1104830405Medicare NSC
WV3810004833Medicaid