=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811066947
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRISTOL SURGICAL ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 02/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MEDICAL PARK BLVD 250 WEST
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37620-7430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-844-6620
-----------------------------------------------------
Fax | 423-844-6627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 MEDICAL PARK BLVD 250 WEST
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37620-7430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-844-6620
-----------------------------------------------------
Fax | 423-844-6627
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. JOHNNA BORDERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-844-6620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------