Basic Information
| Provider Information | |||||||||
| NPI: | 1790844132 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIDGE LAKE ASC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 RIDGE LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016852200 | ||||||||
| FaxNumber: | 9018202342 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 RIDGE LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016852200 | ||||||||
| FaxNumber: | 9018202342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | GOLLAMUDI | ||||||||
| AuthorizedOfficialFirstName: | SUBBA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9016852200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0000000049 | TN | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QS0132X | 0000000049 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery |
ID Information
| ID | Type | State | Issuer | Description | Q016777 | 05 | TN | MEDICAID | 00074013 | 05 | MS | MEDICAID | 190552128 | 05 | AR | MEDICAID |