1245340603 NPI number — MOUNTAIN EMPIRE CATARACT & EYE SURGERY CENTER

Table of content: (NPI 1245340603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245340603 NPI number — MOUNTAIN EMPIRE CATARACT & EYE SURGERY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN EMPIRE CATARACT & EYE SURGERY CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245340603
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3185 W STATE ST
Provider Second Line Business Mailing Address:
SUITE 2020
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37620-1610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-968-4141
Provider Business Mailing Address Fax Number:
423-968-7641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3185 W STATE ST
Provider Second Line Business Practice Location Address:
SUITE 2020
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-1610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-968-4141
Provider Business Practice Location Address Fax Number:
423-968-7641
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BURTON
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
877-969-0392

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  152 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010024676 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4068468 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P00056474 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: TN0101 . This is a "JOHN DEERE HEALTH CARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 019997 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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