Provider Demographics
NPI:1356405120
Name:HOLSTON MEDICAL GROUP PC
Entity type:Organization
Organization Name:HOLSTON MEDICAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWSON
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:423-857-2030
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:1H
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:423-392-6593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000100137Medicaid
TN0281780003Medicare PIN
TNP00092115Medicare PIN
TN0281780001Medicare PIN