1255471439 NPI number — MS EYE CARE, PA

Table of content: (NPI 1255471439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255471439 NPI number — MS EYE CARE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MS EYE CARE, PA
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:
6
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:
1255471439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 628
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-446-9000
Provider Business Mailing Address Fax Number:
662-779-4030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 DECATUR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39345-2309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-683-3241
Provider Business Practice Location Address Fax Number:
601-683-3233
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
IVEY
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OD/OWNER
Authorized Official Telephone Number:
601-683-3241

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  560 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00087007 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09351503 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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