Provider Demographics
NPI:1619487782
Name:UCH VASCULAR ACCESS ASC LLC
Entity Type:Organization
Organization Name:UCH VASCULAR ACCESS ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-866-8864
Mailing Address - Street 1:1407 UNION AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3641
Mailing Address - Country:US
Mailing Address - Phone:901-866-8037
Mailing Address - Fax:
Practice Address - Street 1:6490 MT MORIAH RD EXT STE 202
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-3841
Practice Address - Country:US
Practice Address - Phone:901-366-5479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ048088Medicaid