Provider Demographics
NPI:1649578386
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:JOHNSON CITY MEDICAL CENTER, REGIONAL CANCER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP
Authorized Official - Prefix:
Authorized Official - First Name:GRACIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-431-7060
Mailing Address - Street 1:1 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 21 ROOM C-17
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6587
Mailing Address - Country:US
Mailing Address - Phone:423-232-6900
Mailing Address - Fax:423-232-6903
Practice Address - Street 1:1 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 21 ROOM C-17
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6587
Practice Address - Country:US
Practice Address - Phone:423-232-6900
Practice Address - Fax:423-232-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty