Healthcare Provider Details

I. General information

NPI: 1710309265
Provider Name (Legal Business Name): MID STATE ENDO UAP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 DOW ST SUITE A
MURFREESBORO TN
37130-2487
US

IV. Provider business mailing address

1115 DOW ST STE A
MURFREESBORO TN
37130-2487
US

V. Phone/Fax

Practice location:
  • Phone: 615-848-9234
  • Fax: 615-893-3188
Mailing address:
  • Phone: 615-848-9234
  • Fax: 615-893-3188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: KRISTEN OCONNOR
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 615-376-7315