Basic Information
| Provider Information | |||||||||
| NPI: | 1053404574 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINGSPORT AMBULATORY SURGERY CTR | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KINGSPORT DAY SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 14201 DALLAS PKWY | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752542916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727633859 | ||||||||
| FaxNumber: | 9729203445 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 PAVILION DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238576300 | ||||||||
| FaxNumber: | 4238576324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MORAN | ||||||||
| AuthorizedOfficialFirstName: | JENETHA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER/AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9727633893 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000113 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 100032523 | 01 | PHP | OTHER | 170411602 | 05 | TX | MEDICAID | 36001311 | 05 | KY | MEDICAID | A3766000 | 01 | JOHN DEERE | OTHER | 227545 | 01 | ANTHEM | OTHER | 3148953 | 01 | BLUE CROSS | OTHER | 007603177 | 05 | VA | MEDICAID | 091618800 | 05 | FL | MEDICAID | 3288120 | 05 | TN | MEDICAID | 7254600 | 01 | CIGNA | OTHER |