Provider Demographics
NPI:1194437624
Name:WATAUGA SURGICAL PARTNERS PLLC
Entity type:Organization
Organization Name:WATAUGA SURGICAL PARTNERS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-282-9011
Mailing Address - Street 1:2410 SUSANNAH STREET
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10425 WALLACE ALLEY STREET
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663
Practice Address - Country:US
Practice Address - Phone:423-282-9011
Practice Address - Fax:423-282-0035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical