Provider Demographics
NPI:1134282551
Name:FRONTIER HEALTH
Entity Type:Organization
Organization Name:FRONTIER HEALTH
Other - Org Name:FAIRVIEW ASSOCIATES OF JOHNSON CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:423-467-3600
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:607 BAXTER ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4003
Practice Address - Country:US
Practice Address - Phone:423-232-2670
Practice Address - Fax:423-928-0381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL-214-076-1412251S00000X, 261QM0801X
TN319261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNSAME AS MEDICARE #SMedicaid
VA49-4914-5Medicaid
VA49-4914-5Medicaid
TN3920247Medicare ID - Type UnspecifiedFOR LCSWS
TNSAME AS MEDICARE #SMedicaid