1003861998 NPI number — PHYSICIANS SURGERY CENTER OF CHATTANOOGA, LLC

Table of content: (NPI 1003861998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003861998 NPI number — PHYSICIANS SURGERY CENTER OF CHATTANOOGA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS SURGERY CENTER OF CHATTANOOGA, LLC
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:
PHYSICIANS SURGERY CENTER OF CHATTANOOGA
Provider Other Organization Name Type Code:
3
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:
1003861998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
924 SPRING CREEK ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37412-3910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-899-1600
Provider Business Mailing Address Fax Number:
423-889-2171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 SPRING CREEK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37412-3910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-899-1600
Provider Business Practice Location Address Fax Number:
423-889-2171
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OCCONOR
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICARE AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-376-7315

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  00071 , 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: 0873969A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3288496 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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