Provider Demographics
NPI:1003851304
Name:ABERDEEN EYE CLINIC P A
Entity Type:Organization
Organization Name:ABERDEEN EYE CLINIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:CONSTANCE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-369-2444
Mailing Address - Street 1:PO BOX 955
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-0955
Mailing Address - Country:US
Mailing Address - Phone:662-369-2444
Mailing Address - Fax:662-369-7223
Practice Address - Street 1:114 N HICKORY ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-2648
Practice Address - Country:US
Practice Address - Phone:662-369-2444
Practice Address - Fax:662-369-7223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00822765Medicaid
MS5381060001Medicare NSC
MS00822765Medicaid