Basic Information
| Provider Information | |||||||||
| NPI: | 1508845942 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENDOSCOPY CENTER OF KNOXVILLE LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE ENDOSCOPY CENTER WEST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1A BURTON HILLS BLVD | ||||||||
| Address2: | ATTN:L&C | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655885121 | ||||||||
| FaxNumber: | 8656750501 | ||||||||
| Practice Location | |||||||||
| Address1: | 11440 PARKSIDE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379341973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655885121 | ||||||||
| FaxNumber: | 8656750501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000179 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3739716 | 05 | TN | MEDICAID |