Provider Demographics
NPI:1740256197
Name:THE ASSOCIATES OF MEMORIAL MISSION SURGERY CENTER, LLC
Entity type:Organization
Organization Name:THE ASSOCIATES OF MEMORIAL MISSION SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIKOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-648-6672
Mailing Address - Street 1:PO BOX 23785
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37422-3785
Mailing Address - Country:US
Mailing Address - Phone:423-648-6672
Mailing Address - Fax:423-648-5312
Practice Address - Street 1:2515 DESALES AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1100
Practice Address - Country:US
Practice Address - Phone:423-648-6672
Practice Address - Fax:423-648-5312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN147261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA261507535AMedicaid
TN3288753Medicaid
TN4053703OtherBCBS OF TN
GA261507535AMedicaid