Basic Information
| Provider Information | |||||||||
| NPI: | 1134120280 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARYVILLE SURGICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 763 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653809070 | ||||||||
| FaxNumber: | 8653809093 | ||||||||
| Practice Location | |||||||||
| Address1: | 763 E LAMAR ALEXANDER PKWY | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378045000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653809070 | ||||||||
| FaxNumber: | 8653809093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RIDER | ||||||||
| AuthorizedOfficialFirstName: | MARY ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8653809070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000107 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3288166 | 05 | TN | MEDICAID |