Provider Demographics
NPI:1578558078
Name:KINGSPORT ENDOSCOPY CORPORATION
Entity Type:Organization
Organization Name:KINGSPORT ENDOSCOPY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:423-246-6777
Mailing Address - Street 1:135 W RAVINE RD
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3847
Mailing Address - Country:US
Mailing Address - Phone:423-246-6777
Mailing Address - Fax:423-246-7766
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:SUITE 7A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-246-6777
Practice Address - Fax:423-246-7766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000055261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007641354Medicaid
VA000815OtherANTHEM
TN001000993OtherBCBS OF TN
KY36000412Medicaid
TN100020225OtherPHP TENNCARE
TN3287295Medicaid
TN100020225OtherPHP TENNCARE
VA007641354Medicaid