Provider Demographics
NPI:1790844132
Name:RIDGE LAKE ASC, LLC
Entity Type:Organization
Organization Name:RIDGE LAKE ASC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SUBBA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOLLAMUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-685-2200
Mailing Address - Street 1:825 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9411
Mailing Address - Country:US
Mailing Address - Phone:901-685-2200
Mailing Address - Fax:901-820-2342
Practice Address - Street 1:825 RIDGE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9411
Practice Address - Country:US
Practice Address - Phone:901-685-2200
Practice Address - Fax:901-820-2342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000049261QA1903X, 261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ016777Medicaid
MS00074013Medicaid
AR190552128Medicaid
TNQ016777Medicaid