1225398480 NPI number — TRI STATE ADVANCED SURGERY CENTER, LLC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225398480 NPI number — TRI STATE ADVANCED SURGERY CENTER, LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI STATE ADVANCED SURGERY CENTER, LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225398480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2596 INTERSTATE 55
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72364-2327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-559-2006
Provider Business Mailing Address Fax Number:
870-559-2413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2596 INTERSTATE 55
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72364-2327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-559-2006
Provider Business Practice Location Address Fax Number:
870-559-2413
Provider Enumeration Date:
05/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
JEFFREY
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
870-559-2006

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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