Provider Demographics
NPI:1134120280
Name:MARYVILLE SURGICAL CENTER
Entity Type:Organization
Organization Name:MARYVILLE SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:865-380-9070
Mailing Address - Street 1:763 E LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5000
Mailing Address - Country:US
Mailing Address - Phone:865-380-9070
Mailing Address - Fax:865-380-9093
Practice Address - Street 1:763 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5000
Practice Address - Country:US
Practice Address - Phone:865-380-9070
Practice Address - Fax:865-380-9093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000107261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3288166Medicaid
TN3288166Medicare ID - Type Unspecified
TN3288166Medicaid