Provider Demographics
NPI:1598700254
Name:MID-SOUTH RETINA ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MID-SOUTH RETINA ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-682-1100
Mailing Address - Street 1:PO BOX 1000 DEPT 448
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0448
Mailing Address - Country:US
Mailing Address - Phone:901-682-1100
Mailing Address - Fax:901-682-6915
Practice Address - Street 1:201 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-8400
Practice Address - Country:US
Practice Address - Phone:662-287-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-SOUTH RETINA ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-18
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS465151795BOtherBLUE CROSS OF MISSISSIPPI
MS465151795OtherAHS STATE OF MS BC
MS04635763Medicaid
MSCN2242Medicare PIN
TNH44349Medicare UPIN
MS04635763Medicaid