Provider Demographics
NPI:1609809326
Name:MISSISSIPPI EYE SURGERY CENTER UC
Entity Type:Organization
Organization Name:MISSISSIPPI EYE SURGERY CENTER UC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:228-244-0067
Mailing Address - Street 1:3432 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:228-244-0067
Mailing Address - Fax:228-244-0071
Practice Address - Street 1:3432 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:228-244-0067
Practice Address - Fax:228-244-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QA0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0900XAmbulatory Health Care FacilitiesClinic/CenterAmputee
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04480379Medicaid
MS04480379Medicaid