Provider Demographics
NPI:1083646491
Name:MEDICAL CENTER ENDOSCOPY GROUP
Entity Type:Organization
Organization Name:MEDICAL CENTER ENDOSCOPY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER OF THE LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:80 HUMPHREYS CTR
Mailing Address - Street 2:#200
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2353
Mailing Address - Country:US
Mailing Address - Phone:901-578-2538
Mailing Address - Fax:901-578-2572
Practice Address - Street 1:80 HUMPHREYS CTR
Practice Address - Street 2:#200
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2353
Practice Address - Country:US
Practice Address - Phone:901-578-2538
Practice Address - Fax:901-578-2572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000046261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3006899OtherBLUE CROSS OF TENNESSEE
TN3287680Medicaid
TN3287680Medicaid