Provider Demographics
| NPI: | 1831110667 |
|---|---|
| Name: | HOLSTON MEDICAL GROUP PC |
| Entity Type: | Organization |
| Organization Name: | HOLSTON MEDICAL GROUP PC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | MD, MEDICAL DIRECTOR |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | ALICIA |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | WRIGHT |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 423-857-2066 |
| Mailing Address - Street 1: | PO BOX 9 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | KINGSPORT |
| Mailing Address - State: | TN |
| Mailing Address - Zip Code: | 37662-0009 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 423-857-2066 |
| Mailing Address - Fax: | 423-857-2070 |
| Practice Address - Street 1: | 105 W STONE DR |
| Practice Address - Street 2: | 3A |
| Practice Address - City: | KINGSPORT |
| Practice Address - State: | TN |
| Practice Address - Zip Code: | 37660-3256 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 423-392-6200 |
| Practice Address - Fax: | 423-392-6583 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-07-21 |
| Last Update Date: | 2023-06-29 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2080P0206X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | Group - Multi-Specialty |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 2085B0100X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| TN | 3720182 | Medicaid | |
| TN | 3720183 | Medicaid | |
| TN | 3720184 | Medicaid | |
| TN | 3720181 | Medicaid | |
| TN | 3700592 | Medicare ID - Type Unspecified | GROUP NUMBER |
| TN | 3700594 | Medicare ID - Type Unspecified | GROUP NUMBER |
| TN | 3720184 | Medicaid | |
| TN | 3720182 | Medicaid | |
| 0281780003 | Medicare NSC | ||
| TN | 3403675 | Medicare ID - Type Unspecified | GROUP NUMBER |
| TN | 3700596 | Medicare ID - Type Unspecified | GROUP NUMBER |
| TN | 3720182 | Medicare ID - Type Unspecified | GROUP NUMBER |
| TN | 3720183 | Medicaid | |
| TN | 3700597 | Medicare ID - Type Unspecified | GROUP NUMBER |
| VA | C06181 | Medicare PIN |
