Provider Demographics
NPI:1922070911
Name:FAYETTEVILLE ASC LLC
Entity type:Organization
Organization Name:FAYETTEVILLE ASC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6153
Mailing Address - Country:US
Mailing Address - Phone:615-263-4011
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:3344 N FUTRALL DR
Practice Address - Street 2:SUITE 3
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4057
Practice Address - Country:US
Practice Address - Phone:479-582-7280
Practice Address - Fax:615-234-1720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR3230261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131577128Medicaid
AR131577128Medicaid
AR11019Medicare PIN
AR490003242Medicare PIN