1477603074 NPI number — VITREORETINAL EYE CENTER, PC

Table of content: (NPI 1477603074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477603074 NPI number — VITREORETINAL EYE CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITREORETINAL EYE CENTER, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477603074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
962 TOMMY MUNRO DR STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BILOXI
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39532-2139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-388-7000
Provider Business Mailing Address Fax Number:
833-849-9899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
962 TOMMY MUNRO DR STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39532-2139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-388-7000
Provider Business Practice Location Address Fax Number:
833-849-9899
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GREMILLION
Authorized Official First Name:
AVIT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
228-388-7000

Provider Taxonomy Codes

  • Taxonomy code: 207WX0107X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X , with the licence number: 17239 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM2500X , with the licence number: 023984 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05109745 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 438354140A . This is a "LA BCBS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 7812033 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1486787 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08623204 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 438354140B . This is a "BLUE CROSS BLUE SHIELD MS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: DE8313 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com