Provider Demographics
NPI:1386813616
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:MSMG FP ST PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-883-8101
Mailing Address - Street 1:16431 WISE ST
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:VA
Mailing Address - Zip Code:24283
Mailing Address - Country:US
Mailing Address - Phone:276-762-2300
Mailing Address - Fax:276-762-0612
Practice Address - Street 1:16431 WISE ST
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:VA
Practice Address - Zip Code:24283
Practice Address - Country:US
Practice Address - Phone:276-762-2300
Practice Address - Fax:276-762-0612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI020157701OtherDEPARTMENT OF LABOR
VA1386813616Medicaid
VAC10529Medicare PIN