Healthcare Provider Details

I. General information

NPI: 1912040676
Provider Name (Legal Business Name): ELIZABETHTON SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 ROGOSIN DR
ELIZABETHTON TN
37643-2963
US

IV. Provider business mailing address

PO BOX 449
KINGSPORT TN
37662-0449
US

V. Phone/Fax

Practice location:
  • Phone: 423-543-7477
  • Fax: 423-543-7480
Mailing address:
  • Phone: 423-857-2066
  • Fax: 423-857-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0003
License Number StateTN

VIII. Authorized Official

Name: STEVE HOPLAND
Title or Position: MANAGER
Credential:
Phone: 423-857-2066