Basic Information
| Provider Information | |||||||||
| NPI: | 1548221781 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | G. BAKER HUBBARD AMBULATORY SURGERY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 616 W FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314220330 | ||||||||
| FaxNumber: | 7314220478 | ||||||||
| Practice Location | |||||||||
| Address1: | 616 W FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314220330 | ||||||||
| FaxNumber: | 7314220478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RUDD | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7314220330 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000030 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3287378 | 05 | TN | MEDICAID |