Provider Demographics
NPI:1811294531
Name:MID-STATE ENDOSCOPY CENTER LLC
Entity type:Organization
Organization Name:MID-STATE ENDOSCOPY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTSHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-800-2017
Mailing Address - Street 1:14201 DALLAS PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2916
Mailing Address - Country:US
Mailing Address - Phone:615-848-9234
Mailing Address - Fax:615-893-3188
Practice Address - Street 1:1115 DOW ST
Practice Address - Street 2:STE A
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-2487
Practice Address - Country:US
Practice Address - Phone:615-848-9234
Practice Address - Fax:615-893-3188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2021-02-01
Deactivation Date:2015-10-12
Deactivation Code:
Reactivation Date:2015-11-30
Provider Licenses
StateLicense IDTaxonomies
TN210367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP01044051OtherRAILROAD MEDICARE
TN103G705085Medicare PIN