Provider Demographics
NPI:1871517151
Name:DICKENSON MEDICAL ASSOCIATES A DEPARTMENT OF DICKENSON COMMUNITY HOSPI
Entity type:Organization
Organization Name:DICKENSON MEDICAL ASSOCIATES A DEPARTMENT OF DICKENSON COMMUNITY HOSPI
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 1:509 MED TECH PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2579
Mailing Address - Country:US
Mailing Address - Phone:423-302-6567
Mailing Address - Fax:
Practice Address - Street 1:364 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228-6786
Practice Address - Country:US
Practice Address - Phone:276-926-0200
Practice Address - Fax:276-926-6675
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DICKENSON COMMUNITY HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-27
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240240207Q00000X
VA0101016773207Q00000X
VA0102201380207R00000X
261QR1300X
VA0017001384363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA18871517151Medicaid
VADC7419OtherRR MEDICARE
VA491303Medicare Oscar/Certification
VADC7419OtherRR MEDICARE