1053404574 NPI number — KINGSPORT AMBULATORY SURGERY CTR

Table of content: (NPI 1053404574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053404574 NPI number — KINGSPORT AMBULATORY SURGERY CTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGSPORT AMBULATORY SURGERY CTR
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:
6
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:
1053404574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14201 DALLAS PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75254-2916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-763-3859
Provider Business Mailing Address Fax Number:
972-920-3445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2204 PAVILION DRIVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-4653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-857-6300
Provider Business Practice Location Address Fax Number:
423-857-6324
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORAN
Authorized Official First Name:
JENETHA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OFFICER/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
972-763-3893

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  0000000113 , 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: 100032523 . This is a "PHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 170411602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36001311 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: A3766000 . This is a "JOHN DEERE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 227545 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3148953 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 007603177 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 091618800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3288120 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7254600 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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