1013964063 NPI number — BRISTOL SURGERY CENTER, LLC

Table of content: (NPI 1013964063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013964063 NPI number — BRISTOL SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRISTOL SURGERY CENTER, 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:
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:
1013964063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 BLOUNTVILLE HWY
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37620-0213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-844-6120
Provider Business Mailing Address Fax Number:
423-844-6119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 BLOUNTVILLE HWY
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37620-0213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-844-6120
Provider Business Practice Location Address Fax Number:
423-844-6119
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
423-844-6120

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  0000000052 , 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: 007192 . This is a "TRIGON BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: TN0103 . This is a "JOHN DEERE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0004618082 . This is a "AETNA PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 007679301 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3287075 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000984 . This is a "BSBSTN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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