Provider Demographics
NPI:1417112277
Name:SOUTHERN EYE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SOUTHERN EYE SURGERY CENTER LLC
Other - Org Name:ANESTHESIA
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING MEMBER/PRESIDENT
Authorized Official - Prefix:
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:601-705-0078
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X
MS010261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512G700151OtherMEDICARE PTAN