Active NPI
Kingsport Ambulatory Surgery Ctr
- Ambulatory Surgical Clinic/Center
- Kingsport, TN
National Provider Identifier
1053404574
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Ambulatory Surgical Clinic/Center
- License
- 0000000113
- Legal business name
- KINGSPORT AMBULATORY SURGERY CTR
- Practice address
- 2204 Pavilion Drive
Suite 300
Kingsport, TN 37660-4653 - Phone
- (423) 857-6300
- Fax
- (423) 857-6324
- NPI assigned
- Oct 2, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Jenetha D Moran
- Title
- Officer/Authorized Official
- Phone
- (972) 763-3893
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Ambulatory Surgical Clinic/Center | 261QA1903X | 0000000113 | TN | Primary |
Addresses
Primary practice location
2204 Pavilion Drive
Suite 300
Kingsport, TN 37660-4653
Mailing address
14201 Dallas Pkwy
Dallas, TX 75254-2916
Phone (972) 763-3859
Other identifiers 10
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100032523 | Other | PHP | |
| 170411602 | Medicaid | TX | |
| 36001311 | Medicaid | KY | |
| A3766000 | Other | JOHN DEERE | |
| 227545 | Other | ANTHEM | |
| 3148953 | Other | BLUE CROSS | |
| 007603177 | Medicaid | VA | |
| 091618800 | Medicaid | FL | |
| 3288120 | Medicaid | TN | |
| 7254600 | Other | CIGNA |
Other names 1
- Kingsport Day Surgery
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
Ambulatory surgical center certification: CCN 44C0001095
Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.
- Legal name
- KINGSPORT AMBULATORY SURGERY CENTER
- Certification status
- Active
- Provider type (POS)
- Ambulatory surgical center
- Participating since
- May 22, 2000
- Last certification
- Sep 14, 2006
- Ownership / control type
- Proprietary
- Facility address
- 2204 Pavilion Drive
Kingsport, TN 37660
National Provider Directory
National Provider DirectoryMember of 4
Organizations this organization is a member of, according to the National Provider Directory.
-
- Internal Medicine Physician
- Johnson City, TN
- NPI 1619349578
Member Of
-
- Ambulatory Surgical Clinic/Center
- Kingsport, TN
- NPI 1356396857
Member Of
Locations
311 Princeton Rd
Ste 1
Johnson City, TN 37601
2204 Pavilion Dr
Ste 300
Kingsport, TN 37660
Phone (423) 246-4155
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1159747200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1578960000000",
"number": "1053404574",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "14201 DALLAS PKWY",
"city": "DALLAS",
"state": "TX",
"postal_code": "752542916",
"telephone_number": "972-763-3859",
"fax_number": "972-920-3445"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2204 PAVILION DRIVE",
"address_2": "SUITE 300",
"city": "KINGSPORT",
"state": "TN",
"postal_code": "376604653",
"telephone_number": "423-857-6300",
"fax_number": "423-857-6324"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "KINGSPORT AMBULATORY SURGERY CTR",
"organizational_subpart": "NO",
"enumeration_date": "2006-10-02",
"last_updated": "2020-01-14",
"certification_date": "2020-01-14",
"status": "A",
"authorized_official_last_name": "MORAN",
"authorized_official_first_name": "JENETHA",
"authorized_official_middle_name": "D",
"authorized_official_title_or_position": "OFFICER/AUTHORIZED OFFICIAL",
"authorized_official_telephone_number": "972-763-3893"
},
"taxonomies": [
{
"code": "261QA1903X",
"taxonomy_group": "",
"desc": "Clinic/Center, Ambulatory Surgical",
"state": "TN",
"license": "0000000113",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PHP",
"identifier": "100032523",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "170411602",
"state": "TX"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "36001311",
"state": "KY"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "JOHN DEERE",
"identifier": "A3766000",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "ANTHEM",
"identifier": "227545",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS",
"identifier": "3148953",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "007603177",
"state": "VA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "091618800",
"state": "FL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "3288120",
"state": "TN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "CIGNA",
"identifier": "7254600",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Kingsport Day Surgery",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Kingsport Day Surgery",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Kingsport, TN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 14, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.