Provider Demographics
NPI:1407984396
Name:EYE M D OPHTHALMOLOGY PLLC
Entity Type:Organization
Organization Name:EYE M D OPHTHALMOLOGY PLLC
Other - Org Name:MAHAN - RIDLEY PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:BOB
Authorized Official - Last Name:MAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-393-6004
Mailing Address - Street 1:926 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2300
Mailing Address - Country:US
Mailing Address - Phone:931-393-6004
Mailing Address - Fax:931-393-4795
Practice Address - Street 1:926 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2300
Practice Address - Country:US
Practice Address - Phone:931-393-6004
Practice Address - Fax:931-393-4795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN-OD-T394152W00000X
TNTN MD18870207W00000X
TNTN MD 9867207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3711455Medicaid
TN3711455Medicare PIN
TN3711455Medicare ID - Type Unspecified
TNB03196Medicare UPIN
TN3711455Medicaid
TN3945012Medicare ID - Type Unspecified
TN3945012Medicaid