Provider Demographics
NPI:1215963350
Name:MID-SOUTH RETINA ASSOCIATES, LLC
Entity type:Organization
Organization Name:MID-SOUTH RETINA ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ERVIN
Authorized Official - Last Name:SIEVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-682-1100
Mailing Address - Street 1:PO BOX 1000 DEPT 448
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0448
Mailing Address - Country:US
Mailing Address - Phone:901-682-1100
Mailing Address - Fax:901-682-6915
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 624B
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5202
Practice Address - Country:US
Practice Address - Phone:901-682-1100
Practice Address - Fax:901-682-6915
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-SOUTH RETINA ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-23
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4067262OtherBLUE CROSS OF TENNESSEE
TN3387047Medicaid
TN3104352OtherBLUE CROSS OF TENNESSEE
TN0053763OtherBLUE CROSS OF TENNESSEE
TN3066300OtherBLUE CROSS OF TENNESSEE
TNA97534Medicare UPIN
TN3387047Medicare PIN
TN4067262OtherBLUE CROSS OF TENNESSEE
TNG02244Medicare UPIN
TNH44349Medicare UPIN
TNE35201Medicare UPIN