Provider Demographics
NPI:1639177751
Name:COLEMAN CATARACT AND EYE LASER SURGERY CENTER, INC
Entity type:Organization
Organization Name:COLEMAN CATARACT AND EYE LASER SURGERY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-455-4523
Mailing Address - Street 1:2005 HIGHWAY 82 W
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-2720
Mailing Address - Country:US
Mailing Address - Phone:662-455-4523
Mailing Address - Fax:662-455-3790
Practice Address - Street 1:2005 HIGHWAY 82 W
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2720
Practice Address - Country:US
Practice Address - Phone:662-455-4523
Practice Address - Fax:662-455-3790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic SurgeryGroup - Single Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770597Medicaid
MS490005565OtherRAILROAD MEDICARE
MS=========OtherBLUE CROSS/BLUE SHIELD OF MS
MS490000037Medicare PIN
MS490005565OtherRAILROAD MEDICARE