Provider Demographics
NPI:1851890636
Name:OLD TOWN ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:OLD TOWN ENDOSCOPY CENTER LLC
Other - Org Name:OLD TOWN ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-240-3740
Mailing Address - Street 1:1A BURTON HILLS BLVD. ATTN: PROVIDER ENROLLMENT
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-922-6102
Mailing Address - Fax:
Practice Address - Street 1:5500 GREENVILLE AVENUE SUITE 1100
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206
Practice Address - Country:US
Practice Address - Phone:214-739-9544
Practice Address - Fax:214-739-9582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty