Healthcare Provider Details

I. General information

NPI: 1174128359
Provider Name (Legal Business Name): JEFFERSON ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6242 W ANDREW JOHNSON HWY
TALBOTT TN
37877-8604
US

IV. Provider business mailing address

6242 W ANDREW JOHNSON HWY
TALBOTT TN
37877-8604
US

V. Phone/Fax

Practice location:
  • Phone: 702-271-8476
  • Fax:
Mailing address:
  • Phone: 423-690-3250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KRISTINA MUSIC
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7377