Provider Demographics
NPI:1609984954
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:JAMES H. & CECILE C. QUILLEN REHABILITATION HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP/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:423-302-3374
Mailing Address - Street 1:311 PRINCETON RD
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:
Mailing Address - Fax:
Practice Address - Street 1:2511 WESLEY ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1723
Practice Address - Country:US
Practice Address - Phone:423-952-1700
Practice Address - Fax:423-431-6525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000121273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004400631Medicaid
KY01620418Medicaid
GA000262138XMedicaid
ALJOH0063NMedicaid
NY01675483Medicaid
OH0579913Medicaid
FL091618800Medicaid
NC440063Medicaid
MS05431336Medicaid
SC463496Medicaid
MI4688190Medicaid
WV9802156000Medicaid
NC440063Medicaid
MI4688190Medicaid