Provider Demographics
NPI:1821082702
Name:CLARKSVILLE ENDOSCOPY CENTER
Entity Type:Organization
Organization Name:CLARKSVILLE ENDOSCOPY CENTER
Other - Org Name:EDWIN C GLASSELL
Other - Org Type:Other Name
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GLASSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-552-0180
Mailing Address - Street 1:132 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5000
Mailing Address - Country:US
Mailing Address - Phone:931-552-0180
Mailing Address - Fax:931-572-0915
Practice Address - Street 1:132 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5000
Practice Address - Country:US
Practice Address - Phone:931-552-0180
Practice Address - Fax:931-572-0915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000069261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3287635Medicaid
TN3287635Medicaid