Basic Information
| Provider Information | |||||||||
| NPI: | 1649244211 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINGSPORT TN OPHTHALMOLOGY ASC LLC | ||||||||
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| OtherOrganizationName: | THE REGIONAL EYE SURGERY CENTER | ||||||||
| 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: | 4232472022 | ||||||||
| FaxNumber: | 4232472027 | ||||||||
| Practice Location | |||||||||
| Address1: | 999 EXECUTIVE PARK BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232472022 | ||||||||
| FaxNumber: | 4232472027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000158 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00057294 | 01 | TN | MEDICARE RAILROAD | OTHER | 3288818 | 05 | TN | MEDICAID |