Provider Demographics
NPI:1417009978
Name:COPPER BASIN COMMUNITY HOSPITAL INC
Entity Type:Organization
Organization Name:COPPER BASIN COMMUNITY HOSPITAL INC
Other - Org Name:COPPER BASIN MED CTR SWING BED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-496-5511
Mailing Address - Street 1:PO BOX 990
Mailing Address - Street 2:
Mailing Address - City:COPPERHILL
Mailing Address - State:TN
Mailing Address - Zip Code:37317-0990
Mailing Address - Country:US
Mailing Address - Phone:423-496-5511
Mailing Address - Fax:423-496-9311
Practice Address - Street 1:144 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:COPPERHILL
Practice Address - State:TN
Practice Address - Zip Code:37317
Practice Address - Country:US
Practice Address - Phone:423-496-5511
Practice Address - Fax:423-496-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000094275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44Z315Medicare Oscar/Certification