Provider Demographics
NPI:1710355649
Name:JOHNSTON MEMORIAL HOSPITAL, INC
Entity Type:Organization
Organization Name:JOHNSTON MEMORIAL HOSPITAL, INC
Other - Org Name:JOHNSTON MEMORIAL SLEEP LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP/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:423-302-3423
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:276-258-4734
Mailing Address - Fax:276-258-4736
Practice Address - Street 1:3175 LINDEN DR STE 3-5
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-5849
Practice Address - Country:US
Practice Address - Phone:276-258-4734
Practice Address - Fax:276-258-4736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH 1864282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA490053Medicare Oscar/Certification