Provider Demographics
NPI:1639530454
Name:MS EYE CARE PA
Entity Type:Organization
Organization Name:MS EYE CARE PA
Other - Org Name:MERIDIAN EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-446-9000
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-0628
Mailing Address - Country:US
Mailing Address - Phone:662-446-9000
Mailing Address - Fax:662-779-4030
Practice Address - Street 1:5002 HIGHWAY 39 N
Practice Address - Street 2:BUILDING B
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1078
Practice Address - Country:US
Practice Address - Phone:601-483-7331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MS EYE CARE PLA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-08
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05208871Medicaid