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General NPI Number Information
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NPI Number | 1790844132
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Entity Type | Organization
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Legal Business Name | RIDGE LAKE ASC, LLC
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Dates
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Enumeration Date | 12/08/2006
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Last Update Date | 07/25/2022
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Provider Practice Location Address
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Address Line | 825 RIDGE LAKE BLVD
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City | MEMPHIS
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State | TN
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Zip | 38120-9411
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Country | US
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Telephone | 901-685-2200
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Fax | 901-820-2342
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Provider Business Mailing Address
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Address Line | 825 RIDGE LAKE BLVD
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City | MEMPHIS
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State | TN
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Zip | 38120-9411
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Country | US
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Telephone | 901-685-2200
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Fax | 901-820-2342
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | SUBBA R GOLLAMUDI
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Credential | MD
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Telephone | 901-685-2200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 0000000049
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 261QS0132X
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Taxonomy Name | Ophthalmologic Surgery Clinic/Center
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License Number | 0000000049
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License Number State | TN
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