Provider Demographics
NPI:1558785683
Name:SOUTHERN SPORTS SURGICAL, LLC.
Entity Type:Organization
Organization Name:SOUTHERN SPORTS SURGICAL, LLC.
Other - Org Name:INDIAN LAKE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-418-2975
Mailing Address - Street 1:127 SAUNDERSVILLE RD.
Mailing Address - Street 2:SUITE A
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-8902
Mailing Address - Country:US
Mailing Address - Phone:615-265-8038
Mailing Address - Fax:615-265-8546
Practice Address - Street 1:127 SAUNDERSVILLE RD.
Practice Address - Street 2:SUITE A
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-8902
Practice Address - Country:US
Practice Address - Phone:615-265-8038
Practice Address - Fax:615-265-8546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical