Provider Demographics
NPI:1679214142
Name:JACKSON MADISON SURGERY CENTER LLC
Entity Type:Organization
Organization Name:JACKSON MADISON SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:901-507-6004
Mailing Address - Street 1:2020 EXETER RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3945
Mailing Address - Country:US
Mailing Address - Phone:901-737-4665
Mailing Address - Fax:901-328-1355
Practice Address - Street 1:700 W FOREST AVE STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3940
Practice Address - Country:US
Practice Address - Phone:901-737-4665
Practice Address - Fax:901-328-1355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical