Provider Demographics
NPI:1104097310
Name:SOUTHEASTERN RETINA ASSOCIATES, P.C.
Entity type:Organization
Organization Name:SOUTHEASTERN RETINA ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVERGHETTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-474-7596
Mailing Address - Street 1:9050 EXECUTIVE PARK DR STE 202A
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4670
Mailing Address - Country:US
Mailing Address - Phone:865-588-0811
Mailing Address - Fax:865-934-3892
Practice Address - Street 1:1961 NORTHPOINT BLVD STE 110
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4556
Practice Address - Country:US
Practice Address - Phone:423-756-1002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3715425Medicaid
TN3715425Medicaid
TNCI4354Medicare PIN
TN3715425Medicaid
AL529903320Medicaid