Provider Demographics
NPI:1346379534
Name:TAKOMA REGIONAL HOSPITAL,INC
Entity Type:Organization
Organization Name:TAKOMA REGIONAL HOSPITAL,INC
Other - Org Name:GREENEVILLE COMMUNITY HOSPITAL REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KRUTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3423
Mailing Address - Street 1:311 PRINCETON RD SUITE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2026
Mailing Address - Country:US
Mailing Address - Phone:423-639-3151
Mailing Address - Fax:423-636-2399
Practice Address - Street 1:401 TAKOMA AVE
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-4647
Practice Address - Country:US
Practice Address - Phone:423-639-3151
Practice Address - Fax:423-636-2399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN54273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN100020449OtherPREFERRED HEALTH
TNA3774401OtherAMERICHOICE
TNA3774301OtherJOHN DEERE
TN0440050Medicaid
TN1000393OtherBLUE CROSS
TN1000393OtherBLUE CROSS