Provider Demographics
NPI:1720273808
Name:MARK SHIREY O.D. LLC
Entity Type:Organization
Organization Name:MARK SHIREY O.D. LLC
Other - Org Name:SOUTHERN VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIREY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:251-634-2144
Mailing Address - Street 1:7921 TANNER WILLIAMS RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-8308
Mailing Address - Country:US
Mailing Address - Phone:251-634-2144
Mailing Address - Fax:251-634-2145
Practice Address - Street 1:7921 TANNER WILLIAMS RD
Practice Address - Street 2:SUITE H
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-8308
Practice Address - Country:US
Practice Address - Phone:251-634-2144
Practice Address - Fax:251-634-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-968-TA-542152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5704190001Medicare NSC
ALK754Medicare PIN