Provider Demographics
NPI:1205846508
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:MSMG FP IM MTN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-542-1333
Mailing Address - Street 1:1901 S SHADY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37683-2021
Mailing Address - Country:US
Mailing Address - Phone:423-727-1100
Mailing Address - Fax:423-727-1105
Practice Address - Street 1:1901 S SHADY ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-2021
Practice Address - Country:US
Practice Address - Phone:423-727-1100
Practice Address - Fax:423-727-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3278673Medicaid
TN3278673Medicaid