Provider Demographics
NPI:1477556306
Name:CHARLES RETINA INSTITUTE PC
Entity Type:Organization
Organization Name:CHARLES RETINA INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-767-4499
Mailing Address - Street 1:1432 KIMBROUGH RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2405
Mailing Address - Country:US
Mailing Address - Phone:901-767-4499
Mailing Address - Fax:901-761-0727
Practice Address - Street 1:1432 KIMBROUGH RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2405
Practice Address - Country:US
Practice Address - Phone:901-767-4499
Practice Address - Fax:901-761-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD8675174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3158650Medicaid
TN3158652Medicare ID - Type Unspecified
TN3158650Medicaid