Provider Demographics
NPI:1386834547
Name:JOHNSTON MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JOHNSTON MEMORIAL HOSPITAL
Other - Org Name:HOSPITALIST OF JOHNSTON MEMORIAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-258-2830
Mailing Address - Street 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7664
Mailing Address - Country:US
Mailing Address - Phone:276-258-4050
Mailing Address - Fax:276-258-4056
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-4050
Practice Address - Fax:276-258-4056
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHNSTON MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-25
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101221395208M00000X
VA0101239640208M00000X
VA0101238469208M00000X
VA0101237946208M00000X
VA0110002132363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACB9307OtherRR MEDICARE
VA618072300OtherDOL/ENERGY & FECA
TN1525980Medicaid
VA032157100OtherBLACK LUNG
VA1104812684Medicaid
G91344Medicare UPIN
TN1525980Medicaid
Q56009Medicare UPIN
VA1104812684Medicaid
VAC00210Medicare PIN
VA013793J10Medicare PIN