Provider Demographics
NPI:1548221781
Name:G. BAKER HUBBARD AMBULATORY SURGERY CENTER
Entity Type:Organization
Organization Name:G. BAKER HUBBARD AMBULATORY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:E
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-422-0330
Mailing Address - Street 1:616 W FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3902
Mailing Address - Country:US
Mailing Address - Phone:731-422-0330
Mailing Address - Fax:731-422-0478
Practice Address - Street 1:616 W FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3902
Practice Address - Country:US
Practice Address - Phone:731-422-0330
Practice Address - Fax:731-422-0478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000030261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3287378Medicaid
TN3287378Medicare ID - Type UnspecifiedMEDICARE