Provider Demographics
NPI:1548216062
Name:PORTLAND SURGICAL, LLC
Entity Type:Organization
Organization Name:PORTLAND SURGICAL, LLC
Other - Org Name:PORTLAND SURGICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7604
Mailing Address - Street 1:103 REDBUD DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1617
Mailing Address - Country:US
Mailing Address - Phone:615-323-8306
Mailing Address - Fax:
Practice Address - Street 1:103 REDBUD DR
Practice Address - Street 2:SUITE D
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1617
Practice Address - Country:US
Practice Address - Phone:615-323-8306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HTI HOSPITAL HOLDINGS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3734179Medicaid
TN3734179Medicaid