Provider Demographics
NPI:1386028439
Name:JOHNSTON MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:JOHNSTON MEMORIAL HOSPITAL, INC
Other - Org Name:JOHNSTON MEMORIAL SURGERY CENTER
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 STE 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:276-258-1480
Mailing Address - Fax:276-525-1436
Practice Address - Street 1:613 CAMPUS DR
Practice Address - Street 2:SUITE 300
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-9703
Practice Address - Country:US
Practice Address - Phone:276-258-1480
Practice Address - Fax:276-525-1436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1864261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
490053Medicare Oscar/Certification