Basic Information
| Provider Information | |||||||||
| NPI: | 1477067866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHOENIX AMBULATORY SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 PHYSICIANS WAY | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370904135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154442320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 PHYSICIANS WAY | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370904135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155219097 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2017 | ||||||||
| LastUpdateDate: | 01/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | FORBES | ||||||||
| AuthorizedOfficialFirstName: | COURTNEY | ||||||||
| AuthorizedOfficialMiddleName: | DISMUKES | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6154490990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | PENDING | 05 | TN | MEDICAID |