Provider Demographics
NPI:1063486504
Name:COLUMBIA ASC NORTHWEST LLC
Entity type:Organization
Organization Name:COLUMBIA ASC NORTHWEST LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:CLENDENIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD
Mailing Address - Street 2:ATTN: L&C
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6103
Mailing Address - Country:US
Mailing Address - Phone:803-407-6767
Mailing Address - Fax:803-407-6757
Practice Address - Street 1:190 PARKRIDGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1747
Practice Address - Country:US
Practice Address - Phone:803-407-6767
Practice Address - Fax:803-407-6757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCASF-076261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCASC048Medicaid
SCASC048Medicaid
SC=========OtherTRICARE
SCQ334200001Medicare PIN
SCP00101502Medicare PIN