Provider Demographics
NPI:1710099742
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:SYCAMORE SHOALS HOSPITAL PSYCHIATRIC UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:HILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3467
Mailing Address - Street 1:311 PRINCETON RD STE 1
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:423-542-1300
Mailing Address - Fax:423-543-5372
Practice Address - Street 1:1501 W ELK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2874
Practice Address - Country:US
Practice Address - Phone:423-542-1300
Practice Address - Fax:423-543-5372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000012273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
29725700OtherMAGELLAN
29725700OtherMAGELLAN