Basic Information
Provider Information
NPI: 1679214142
EntityType: 2
ReplacementNPI:  
OrganizationName: JACKSON MADISON SURGERY CENTER LLC
LastName:  
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Credential:  
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Mailing Information
Address1: 2020 EXETER RD
Address2:  
City: GERMANTOWN
State: TN
PostalCode: 381383945
CountryCode: US
TelephoneNumber: 9017374665
FaxNumber: 9013281355
Practice Location
Address1: 700 W FOREST AVE STE 100
Address2:  
City: JACKSON
State: TN
PostalCode: 383013940
CountryCode: US
TelephoneNumber: 9017374665
FaxNumber: 9013281355
Other Information
ProviderEnumerationDate: 04/06/2022
LastUpdateDate: 04/06/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ROUSE
AuthorizedOfficialFirstName: BOBBY
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: ASSISTANT SECRETARY
AuthorizedOfficialTelephone: 9015076004
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix: JR.
AuthorizedOfficialCredential:  
NPICertificationDate: 04/06/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QA1903X  Y Ambulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical

No ID Information.


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