Provider Demographics
NPI:1184737017
Name:MS EYE CARE PA
Entity type:Organization
Organization Name:MS EYE CARE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 826
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-0826
Mailing Address - Country:US
Mailing Address - Phone:662-446-9000
Mailing Address - Fax:662-779-4030
Practice Address - Street 1:3027 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341-2275
Practice Address - Country:US
Practice Address - Phone:662-726-6111
Practice Address - Fax:662-726-6110
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MS EYE CARE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS762152W00000X
MS560152W00000X
MS517152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05208871Medicaid
MSC02381Medicare PIN
MS04230256Medicaid