Provider Demographics
NPI:1811066947
Name:BRISTOL SURGICAL ASSOCIATES PC
Entity type:Organization
Organization Name:BRISTOL SURGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOHNNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-844-6620
Mailing Address - Street 1:1 MEDICAL PARK BLVD
Mailing Address - Street 2:250 WEST
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7430
Mailing Address - Country:US
Mailing Address - Phone:423-844-6620
Mailing Address - Fax:423-844-6627
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:250 WEST
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-6620
Practice Address - Fax:423-844-6627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN022276800OtherBLACK LUNG GROUP
TN0636398OtherUMWA GROUP
TNF03906748OtherCHAMPUS GROUP
TN093410OtherANTHEM BCBS VA GROUP
TNCA8128OtherRAILROAD MEDICARE GROUP
TN3386543Medicaid
TN3386543Medicare ID - Type UnspecifiedMEDICARE GROUP