Provider Demographics
NPI:1003437138
Name:SOUTHEAST EYE SPECIALISTS PLLC
Entity Type:Organization
Organization Name:SOUTHEAST EYE SPECIALISTS PLLC
Other - Org Name:SOUTHEAST EYE SPECIALISTS MIDDLE TN
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CRUDUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-0450
Mailing Address - Street 1:341 COOL SPRINGS BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7224
Mailing Address - Country:US
Mailing Address - Phone:423-508-7337
Mailing Address - Fax:423-508-7338
Practice Address - Street 1:28 WHITE BRIDGE ROAD
Practice Address - Street 2:SUITE 208
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37205
Practice Address - Country:US
Practice Address - Phone:615-327-2001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST EYE SPECIALISTS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-04-29
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma SpecialistGroup - Multi-Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Multi-Specialty
No207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases SpecialistGroup - Multi-Specialty
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA524169578AMedicaid
TN3721447Medicaid
GRP6156OtherMEDICARE PIN
GAGRP6156Medicaid
TN3721447OtherMEDICARE PIN