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Organization
KINGSPORT AMBULATORY SURGERY CTR
Active
Organization
KINGSPORT AMBULATORY SURGERY CTR
Active
Other names
Kingsport Day Surgery
Organization subpart
No
Provider details
NPI number
Authorized official
JENETHA D MORAN (OFFICER/AUTHORIZED OFFICIAL)
(972) 763-3893
Entity
Organization
Contact information
Practice address
2204 PAVILION DRIVE, SUITE 300, KINGSPORT, TN 37660-4653
(423) 857-6300
(423) 857-6324
Mailing address
14201 DALLAS PKWY, DALLAS, TX 75254-2916
(972) 763-3859
(972) 920-3445
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
0000000113
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
007603177
—
VA
05
—
091618800
—
FL
01
—
100032523
PHP
—
05
—
170411602
—
TX
01
—
227545
ANTHEM
—
01
—
3148953
BLUE CROSS
—
05
—
3288120
—
TN
05
—
36001311
—
KY
01
—
7254600
CIGNA
—
01
—
A3766000
JOHN DEERE
—
Enumeration date
10/02/2006
Last updated
01/14/2020
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