Provider Demographics
NPI:1356307565
Name:AMBULATORY SURGICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:AMBULATORY SURGICAL ASSOCIATES LLC
Other - Org Name:TULLAHOMA SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:725 KINGS LN
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-5372
Mailing Address - Country:US
Mailing Address - Phone:931-455-1976
Mailing Address - Fax:931-455-7122
Practice Address - Street 1:725 KINGS LN
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-5372
Practice Address - Country:US
Practice Address - Phone:931-455-1976
Practice Address - Fax:931-455-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-25
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000148261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3288744Medicaid
TN4059247OtherBLUE CROSS/ BLUE SHIELD
TNP00024652OtherRAILROAD MEDICARE
TN3288744Medicaid
TNP00024652OtherRAILROAD MEDICARE