Basic Information
| Provider Information | |||||||||
| NPI: | 1467601625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MNH GI SURGICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | MNH SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 COMMERCE ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372192446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153456900 | ||||||||
| FaxNumber: | 6156917214 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 CONCOURSE PKWY S STE 100 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327518101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076444222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2008 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | HOLST | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153456900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1147200 | 05 | FL | MEDICAID |