Provider Demographics
NPI:1679570998
Name:TAKOMA REGIONAL HOSPITAL INC
Entity type:Organization
Organization Name:TAKOMA REGIONAL HOSPITAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:HILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3467
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:423-638-9226
Mailing Address - Fax:423-638-1561
Practice Address - Street 1:801 E MCKEE ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-6010
Practice Address - Country:US
Practice Address - Phone:423-638-9226
Practice Address - Fax:423-638-1561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN620701119313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0125021OtherBLUE CROSS - BLUE SHIELD
TN0740620001OtherPALMETTO GOVERNMENT ADMIN
TN7440545Medicaid
TN0445264Medicaid
TN445264Medicare Oscar/Certification
TN445264Medicare ID - Type Unspecified