Provider Demographics
NPI:1770044497
Name:TRI COUNTY EYE CLINIC, PLLC
Entity Type:Organization
Organization Name:TRI COUNTY EYE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPHTHALMOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:EMILE
Authorized Official - Last Name:BERTUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-385-2020
Mailing Address - Street 1:431 BERTUCCI BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2255
Mailing Address - Country:US
Mailing Address - Phone:228-385-2020
Mailing Address - Fax:228-388-9435
Practice Address - Street 1:3430 BIENVILLE BOULEVARD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5732
Practice Address - Country:US
Practice Address - Phone:228-875-6658
Practice Address - Fax:228-875-0809
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI COUNTY EYE CLINIC, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014787Medicaid