1558785683 NPI number — SOUTHERN SPORTS SURGICAL, LLC.

Table of content: (NPI 1558785683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558785683 NPI number — SOUTHERN SPORTS SURGICAL, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN SPORTS SURGICAL, 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:
INDIAN LAKE SURGERY CENTER
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:
1558785683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 SAUNDERSVILLE RD.
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
HENDERSONVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37075-8902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-265-8038
Provider Business Mailing Address Fax Number:
615-265-8546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
127 SAUNDERSVILLE RD.
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HENDERSONVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37075-8902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-265-8038
Provider Business Practice Location Address Fax Number:
615-265-8546
Provider Enumeration Date:
02/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GAUTSCH
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
615-418-2975

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com