Basic Information
| Provider Information | |||||||||
| NPI: | 1114996774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REDBIRD SQUARE ENDOSCOPY CENTER LLC | ||||||||
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| OtherOrganizationName: | DIGESTIVE HEALTH CENTER AT REDBIRD SQUARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1A BURTON HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152403741 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3107 W CAMP WISDOM RD STE 189 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752372638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143312922 | ||||||||
| FaxNumber: | 2143310413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 007032 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 087966001 | 05 | TX | MEDICAID |