1811294531 NPI number — MID-STATE ENDOSCOPY CENTER LLC

Table of content: (NPI 1811294531)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811294531 NPI number — MID-STATE ENDOSCOPY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-STATE ENDOSCOPY 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:
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:
1811294531
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/12/2015
NPI Reactivation Date:
11/30/2015

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:
615-848-9234
Provider Business Mailing Address Fax Number:
615-893-3188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 DOW ST
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
MURFREESBORO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37130-2487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-848-9234
Provider Business Practice Location Address Fax Number:
615-893-3188
Provider Enumeration Date:
02/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HARTSHORN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
314-800-2017

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  210 , 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: P01044051 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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