Provider Demographics
NPI:1659360071
Name:EAST TENNESSEE AMBULATORY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:EAST TENNESSEE AMBULATORY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRANTNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-283-7302
Mailing Address - Street 1:701 MED TECH PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2259
Mailing Address - Country:US
Mailing Address - Phone:423-283-7302
Mailing Address - Fax:423-282-3670
Practice Address - Street 1:701 MED TECH PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2259
Practice Address - Country:US
Practice Address - Phone:423-283-7302
Practice Address - Fax:423-282-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000109261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
145422OtherUMWA
0007447071OtherAETNA
3135707OtherBCBS OF TN
TN3288092Medicaid
TN3135707OtherBCBS TENNCARE
TN3288092Medicaid
0007447071OtherAETNA