1932107455 NPI number — SOUTHERN EYE ASSOCIATES, PC

Table of content: (NPI 1932107455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932107455 NPI number — SOUTHERN EYE ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN EYE ASSOCIATES, 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:
1932107455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2044
Provider Second Line Business Mailing Address:
DEPT 5700
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38101-2044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-683-4600
Provider Business Mailing Address Fax Number:
901-255-5611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5350 POPLAR AVE
Provider Second Line Business Practice Location Address:
STE 950
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38119-0604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-683-4600
Provider Business Practice Location Address Fax Number:
901-683-8401
Provider Enumeration Date:
07/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JENNINGS
Authorized Official First Name:
LORI
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
901-255-5625

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3944178 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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