Provider Demographics
NPI:1932107455
Name:SOUTHERN EYE ASSOCIATES, PC
Entity Type:Organization
Organization Name:SOUTHERN EYE ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-255-5625
Mailing Address - Street 1:PO BOX 2044
Mailing Address - Street 2:DEPT 5700
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38101-2044
Mailing Address - Country:US
Mailing Address - Phone:901-683-4600
Mailing Address - Fax:901-255-5611
Practice Address - Street 1:5350 POPLAR AVE
Practice Address - Street 2:STE 950
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0604
Practice Address - Country:US
Practice Address - Phone:901-683-4600
Practice Address - Fax:901-683-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3944178Medicaid
MSC02611Medicare ID - Type Unspecified
TN3944178Medicaid
TN3944178Medicare ID - Type Unspecified