1649675364 NPI number — MAURICE JAMES OPHTHALMOLOGY, PA

Table of content: (NPI 1649675364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649675364 NPI number — MAURICE JAMES OPHTHALMOLOGY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAURICE JAMES OPHTHALMOLOGY, 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:
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:
1649675364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
971 LAKELAND DR
Provider Second Line Business Mailing Address:
SUITE 563
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39216-4643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-362-4467
Provider Business Mailing Address Fax Number:
601-362-0239

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
971 LAKELAND DR
Provider Second Line Business Practice Location Address:
SUITE 563
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-362-4467
Provider Business Practice Location Address Fax Number:
601-362-0239
Provider Enumeration Date:
10/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
IVY
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
Authorized Official Title or Position:
INSURANCE MANAGER
Authorized Official Telephone Number:
601-362-4467

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  8996 , 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: 0010144 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 428989680A . This is a "BLUE CROSS BLUE SHIELD PIN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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