Provider Demographics
NPI:1689600215
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:731-286-1240
Mailing Address - Fax:901-682-6915
Practice Address - Street 1:401 E TICKLE ST
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3163
Practice Address - Country:US
Practice Address - Phone:731-286-1240
Practice Address - Fax:901-682-6915
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-SOUTH RETINA ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-24
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3066300OtherBLUE CROSS OF TENNESSEE
TN3050718Medicaid
TN3066300OtherBLUE CROSS OF TENNESSEE
TNE35201Medicare UPIN
TN3387047Medicare PIN