Provider Demographics
NPI:1609806389
Name:SURGICAL ASSOCIATES OF KINGSPORT, INC
Entity Type:Organization
Organization Name:SURGICAL ASSOCIATES OF KINGSPORT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:O
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-245-6101
Mailing Address - Street 1:444 CLINCHFIELD STREET
Mailing Address - Street 2:SUITE 2900
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3858
Mailing Address - Country:US
Mailing Address - Phone:723-245-6101
Mailing Address - Fax:423-245-2396
Practice Address - Street 1:444 CLINCHFIELD STREET
Practice Address - Street 2:SUITE 2900
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3858
Practice Address - Country:US
Practice Address - Phone:723-245-6101
Practice Address - Fax:423-245-2396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
20009693OtherRAILROAD MEDICARE GROUP #
TN2007130OtherBCBS TENNESSEE GROUP #
TN3375800Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER