Provider Demographics
NPI:1073791158
Name:SOUTHERN EYE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SOUTHERN EYE SURGERY CENTER LLC
Other - Org Name:SOUTHERN EYE CENTER OF EXCELLENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCMAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-264-3937
Mailing Address - Street 1:1420 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3107
Mailing Address - Country:US
Mailing Address - Phone:601-264-3937
Mailing Address - Fax:601-264-5930
Practice Address - Street 1:1420 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3107
Practice Address - Country:US
Practice Address - Phone:601-264-3937
Practice Address - Fax:601-264-5930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS010261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770066Medicaid
MS512G490003OtherMEDICARE PTAN FOR SOUTHERN EYE SURGERY CENTER LLC