Basic Information
| Provider Information | |||||||||
| NPI: | 1235140385 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENDOSCOPY CENTER OF KINGSPORT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SULLIVAN DIGESTIVE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 PAVILION DR | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233926100 | ||||||||
| FaxNumber: | 4233926159 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 PAVILION DR STE 108 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233926100 | ||||||||
| FaxNumber: | 4233926159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LLOYD | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
| AuthorizedOfficialMiddleName: | LEIGH | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4233926100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | 0000000053 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 1000910 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER | 3287396 | 05 | TN | MEDICAID |