Organization
RIDGE LAKE ASC, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SUBBA R GOLLAMUDI MD (MANAGING PARTNER)
(901) 685-2200
Entity
Organization
Contact information
Practice address
825 RIDGE LAKE BLVD, MEMPHIS, TN 38120-9411
(901) 685-2200
(901) 820-2342
Mailing address
825 RIDGE LAKE BLVD, MEMPHIS, TN 38120-9411
(901) 685-2200
(901) 820-2342
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
0000000049
TN
261QS0132X
Ophthalmologic Surgery Clinic/Center
Primary
0000000049
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00074013
—
MS
05
—
190552128
—
AR
05
—
Q016777
—
TN
Enumeration date
12/08/2006
Last updated
07/25/2022
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