Basic Information
| Provider Information | |||||||||
| NPI: | 1811074859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICAL MONITORING SERVICES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SURGICAL MONITORING SERVICES, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MARYLAND FARMS STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003484565 | ||||||||
| FaxNumber: | 6153455405 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 MARYLAND FARMS STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003484565 | ||||||||
| FaxNumber: | 6153455405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 12/19/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP, CFO & CRO | ||||||||
| AuthorizedOfficialTelephone: | 8003484565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1811074859 | 05 | VA | MEDICAID | 313953 | 05 | AZ | MEDICAID | 418219700 | 05 | MD | MEDICAID | 432840700 | 05 | ME | MEDICAID | 004265957 | 05 | CT | MEDICAID | 1015358060001 | 05 | PA | MEDICAID | 200806520A | 05 | IN | MEDICAID | 507408003 | 05 | MO | MEDICAID | 7135619 | 05 | WA | MEDICAID | 73883875 | 05 | CO | MEDICAID | GP4366 | 05 | SC | MEDICAID |