NPIMap

Organization Active NPI

Kingsport Ambulatory Surgery Ctr

Doing business as Kingsport Day Surgery

  • Ambulatory Surgical Clinic/Center
  • Kingsport, TN
National Provider Identifier
1053404574
Registry record updated Jan 14, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X
License
0000000113 Issued in TN
Legal business name
KINGSPORT AMBULATORY SURGERY CTR
Doing business as
Kingsport Day Surgery
Practice address
2204 Pavilion Drive
Suite 300
Kingsport, TN 37660-4653
Phone
(423) 857-6300
Fax
(423) 857-6324
NPI assigned
Oct 2, 2006
Last updated
Jan 14, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 14, 2020

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)CodeLicenseStatePrimary
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 names 1

  • Kingsport Day Surgery Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1053404574. Details of each certification follow.

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 Directory

Member of 3

Organizations this organization is a member of, according to the National Provider Directory.

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": [],
    "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

Verify at the official NPI Registry.