1659546802 NPI number — PICAYUNE EYE CLINIC

Table of content: (NPI 1659546802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659546802 NPI number — PICAYUNE EYE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PICAYUNE EYE CLINIC
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:
1659546802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
908 SIXTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PICAYUNE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-798-4182
Provider Business Mailing Address Fax Number:
601-798-4770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1249 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLARVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39470-3313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-795-0137
Provider Business Practice Location Address Fax Number:
601-798-4770
Provider Enumeration Date:
04/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BLACKMER
Authorized Official First Name:
LORI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-798-4182

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  559 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 584 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 09014613 . This is a "MS MEDICAID GROUP PROV#" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 410000163 . This is a "MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 410012249 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 425297177 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00880221 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0661580001 . This is a "PALMETTO GBA DMERC" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 263673909 . This is a "LORI. L BLACKMER- BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: U92635 . This is a "UPIN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00880022 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1346215274 . This is a "MARC A. HAUTOT- NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1750350070 . This is a "BETHANY HARRINGTON, O.D. NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1760451595 . This is a "LORI L. BLACKMER, . O.D. NPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 22-30045 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 435044954D . This is a "BLUE CROSS BLUE SHIELD-DR MARC A. HAUTOT" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: MS0685 . This is a "EYE MED" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: P00043499 . This is a "MEDICARE RAILROAD RETIREMENT" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00087010 . This is a "LORI L. BLACKMER, O.D. MEDICAID" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 410000162 . This is a "MEDICARE-DR MARC A. HAUTOT" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 410000267 . This is a "MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: T95634 . This is a "LORI L. BLACKMER, O.D. UPIN" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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