Basic Information
| Provider Information | |||||||||
| NPI: | 1073598066 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY SURGERY CENTER LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 409184 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303849184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152616000 | ||||||||
| FaxNumber: | 6152616052 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 CHARLOTTE AVE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372094035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152509302 | ||||||||
| FaxNumber: | 6152509301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DANIELSON | ||||||||
| AuthorizedOfficialFirstName: | MARY ELLEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR FACILITY ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6152509314 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000019 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1000990 | 01 | TN | BLUE CROSS | OTHER | 3287149 | 05 | TN | MEDICAID |