Provider Demographics
NPI:1144650722
Name:SRS-ELY LLC
Entity type:Organization
Organization Name:SRS-ELY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:SEYMOUR
Authorized Official - Last Name:TANNENBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHS, FACP
Authorized Official - Phone:615-467-0140
Mailing Address - Street 1:PO BOX 198813
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-8813
Mailing Address - Country:US
Mailing Address - Phone:615-467-0140
Mailing Address - Fax:615-259-0693
Practice Address - Street 1:701 EAST 15TH STREET
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301
Practice Address - Country:US
Practice Address - Phone:615-467-0140
Practice Address - Fax:615-259-0693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV292550Medicare Oscar/Certification