Provider Demographics
NPI:1245781954
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:MSMG RURAL HEALTH CLIINIC LEBANON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5185
Mailing Address - Street 1:58 CARROLL ST SUITE 3
Mailing Address - Street 2:DEPT OF RUSSELL COUNTY MEDICAL CENTER
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-883-8340
Mailing Address - Fax:276-883-8341
Practice Address - Street 1:58 CARROLL ST SUITE 3
Practice Address - Street 2:DEPT OF RUSSELL COUNTY MEDICAL CENTER
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-883-8340
Practice Address - Fax:276-883-8341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1245781954Medicaid
VA020157701OtherDEPARTMENT OF LABOR
VAG368Medicare PIN