Provider Demographics
NPI:1477603074
Name:VITREORETINAL EYE CENTER, PC
Entity Type:Organization
Organization Name:VITREORETINAL EYE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AVIT
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREMILLION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-388-7000
Mailing Address - Street 1:962 TOMMY MUNRO DR STE E
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2139
Mailing Address - Country:US
Mailing Address - Phone:228-388-7000
Mailing Address - Fax:833-849-9899
Practice Address - Street 1:962 TOMMY MUNRO DR STE E
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2139
Practice Address - Country:US
Practice Address - Phone:228-388-7000
Practice Address - Fax:833-849-9899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207WX0107X
MS17239261QM2500X
LA023984261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05109745Medicaid
LA438354140AOtherLA BCBS
MS7812033OtherAETNA
LA1486787Medicaid
MS08623204Medicaid
MS438354140BOtherBLUE CROSS BLUE SHIELD MS
MSDE8313OtherMEDICARE RAILROAD
H08422Medicare UPIN
MSDE8313OtherMEDICARE RAILROAD
MS438354140BOtherBLUE CROSS BLUE SHIELD MS
MSH08422Medicare UPIN