Provider Demographics
NPI:1760486369
Name:MOUNTAIN EMPIRE SURGERY CENTER LP
Entity type:Organization
Organization Name:MOUNTAIN EMPIRE SURGERY CENTER LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:OCONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-376-7315
Mailing Address - Street 1:601 MED TECH PKWY
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2253
Mailing Address - Country:US
Mailing Address - Phone:423-610-1020
Mailing Address - Fax:423-610-1021
Practice Address - Street 1:601 MED TECH PKWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-610-1020
Practice Address - Fax:423-610-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000120261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3281998Medicaid
TN3150816OtherBLUE CROSS BLUE SHIELD
TN490004752OtherMEDICARE RAILROAD
TN3288212Medicare PIN
TN44C0001097Medicare Oscar/Certification