Basic Information
| Provider Information | |||||||||
| NPI: | 1306898416 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGSPORT BRONCHOSCOPY CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 W STONE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232475197 | ||||||||
| FaxNumber: | 4232475254 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W STONE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232475197 | ||||||||
| FaxNumber: | 4232475254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | HAWKINS | ||||||||
| AuthorizedOfficialFirstName: | SHIRLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4232475197 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000054 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1000908 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 3287305 | 05 | TN | MEDICAID |