Provider Demographics
NPI:1679992358
Name:DICKENSON COMMUNITY HOSPITAL, INC.
Entity Type:Organization
Organization Name:DICKENSON COMMUNITY HOSPITAL, INC.
Other - Org Name:DMA BEHAVIORAL HEALTH GREEN OAK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-915-5185
Mailing Address - Street 1:509 MED TECH PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2579
Mailing Address - Country:US
Mailing Address - Phone:423-952-2120
Mailing Address - Fax:
Practice Address - Street 1:364 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228
Practice Address - Country:US
Practice Address - Phone:276-926-0330
Practice Address - Fax:276-926-0254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1871517151Medicaid
VADC7419OtherRR MEDICARE
VA1871517151Medicaid