Provider Demographics
NPI:1801823638
Name:TRI STATE MOUNTAIN NEUROLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:TRI STATE MOUNTAIN NEUROLOGY ASSOCIATES PC
Other - Org Name:NEUROLOGY ASSOCIATES OF JOHNSON CITY PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WHALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-928-6174
Mailing Address - Street 1:1321 SUNSET DRIVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7902
Mailing Address - Country:US
Mailing Address - Phone:423-928-6174
Mailing Address - Fax:423-926-2258
Practice Address - Street 1:1321 SUNSET DRIVE
Practice Address - Street 2:SUITE 11
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7902
Practice Address - Country:US
Practice Address - Phone:423-928-6174
Practice Address - Fax:423-926-2258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
164888600OtherOWCP
TN000009788OtherBCBS
TN3380796Medicaid
TN000009788OtherBCBS