Provider Demographics
NPI:1760414056
Name:VAN DYCK ASC, LLC
Entity Type:Organization
Organization Name:VAN DYCK ASC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:LODEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-642-5003
Mailing Address - Street 1:1024 KELLEY DR
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-4500
Mailing Address - Country:US
Mailing Address - Phone:731-642-5003
Mailing Address - Fax:731-642-8756
Practice Address - Street 1:1024 KELLEY DR
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4500
Practice Address - Country:US
Practice Address - Phone:731-642-5003
Practice Address - Fax:731-642-8756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000023261QA1903X
TNTN23261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3288423Medicaid
TN3288423Medicare PIN