Provider Demographics
NPI:1235140385
Name:ENDOSCOPY CENTER OF KINGSPORT
Entity Type:Organization
Organization Name:ENDOSCOPY CENTER OF KINGSPORT
Other - Org Name:SULLIVAN DIGESTIVE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:LLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-392-6100
Mailing Address - Street 1:2204 PAVILION DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4657
Mailing Address - Country:US
Mailing Address - Phone:423-392-6100
Mailing Address - Fax:423-392-6159
Practice Address - Street 1:2204 PAVILION DR STE 108
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4651
Practice Address - Country:US
Practice Address - Phone:423-392-6100
Practice Address - Fax:423-392-6159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000053261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1000910OtherBLUE CROSS BLUE SHIELD
TN3287396Medicaid
TN3287396Medicaid