Provider Demographics
NPI:1720468200
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:MOUNTAIN STATES REHABILITATION AT IPMC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORP DIRECTOR REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WILGOCKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-431-5794
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:423-857-6777
Mailing Address - Fax:423-857-6788
Practice Address - Street 1:2204 PAVILION DR
Practice Address - Street 2:SUITE 115
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4657
Practice Address - Country:US
Practice Address - Phone:423-857-6777
Practice Address - Fax:423-857-6788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-01
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN134282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN440176Medicare Oscar/Certification