Provider Demographics
NPI:1295240596
Name:SOUTHERN RETINAL INSTITUTE, LLC
Entity type:Organization
Organization Name:SOUTHERN RETINAL INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORD.
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-584-2127
Mailing Address - Street 1:2800 VETERANS MEMORIAL BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-6175
Mailing Address - Country:US
Mailing Address - Phone:504-264-9428
Mailing Address - Fax:504-264-9438
Practice Address - Street 1:2800 VETERANS MEMORIAL BLVD STE 160
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-6175
Practice Address - Country:US
Practice Address - Phone:504-264-9428
Practice Address - Fax:504-264-9438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202072207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1162353Medicaid
MS01602071Medicaid