Provider Demographics
NPI:1508907221
Name:OPHTHALMIC PLASTIC SURGICAL ASSOC PC
Entity Type:Organization
Organization Name:OPHTHALMIC PLASTIC SURGICAL ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONA
Authorized Official - Middle Name:WALKER
Authorized Official - Last Name:BEALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-483-1217
Mailing Address - Street 1:401 DAFFODIL CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-4712
Mailing Address - Country:US
Mailing Address - Phone:901-483-1217
Mailing Address - Fax:615-807-1979
Practice Address - Street 1:401 DAFFODIL CT
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-4712
Practice Address - Country:US
Practice Address - Phone:901-483-1217
Practice Address - Fax:615-807-1979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD000005223207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3386525Medicaid
TN3386525Medicare ID - Type Unspecified