Provider Demographics
NPI:1730123159
Name:JOHNSTON MEMORIAL HOSPITAL, INC
Entity type:Organization
Organization Name:JOHNSTON MEMORIAL HOSPITAL, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:276-252-1277
Mailing Address - Fax:276-525-1236
Practice Address - Street 1:312 CUMMINGS ST
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-3230
Practice Address - Country:US
Practice Address - Phone:276-525-1227
Practice Address - Fax:276-525-1236
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHNSTON MEMORIAL HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-15
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH1864251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA114600OtherANTHEM BLUE CROSS
VA004973411Medicaid
VA497492AMedicare Oscar/Certification