Provider Demographics
NPI:1053404574
Name:KINGSPORT AMBULATORY SURGERY CTR
Entity type:Organization
Organization Name:KINGSPORT AMBULATORY SURGERY CTR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:14201 DALLAS PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2916
Mailing Address - Country:US
Mailing Address - Phone:972-763-3859
Mailing Address - Fax:972-920-3445
Practice Address - Street 1:2204 PAVILION DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4653
Practice Address - Country:US
Practice Address - Phone:423-857-6300
Practice Address - Fax:423-857-6324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000113261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
100032523OtherPHP
TX170411602Medicaid
KY36001311Medicaid
A3766000OtherJOHN DEERE
227545OtherANTHEM
3148953OtherBLUE CROSS
VA007603177Medicaid
FL091618800Medicaid
TN3288120Medicaid
7254600OtherCIGNA
TN3148953Medicare PIN