Provider Demographics
NPI:1639891088
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:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-427-7799
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:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-682-1100
Mailing Address - Fax:
Practice Address - Street 1:6760 GOODMAN RD STE 125
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7056
Practice Address - Country:US
Practice Address - Phone:901-682-1100
Practice Address - Fax:731-265-2913
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-SOUTH RETINA ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-13
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty