Provider Demographics
NPI:1740357334
Name:MISSISSIPPI RETINA ASSOCIATES,PLLC
Entity type:Organization
Organization Name:MISSISSIPPI RETINA ASSOCIATES,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JUDE
Authorized Official - Last Name:BORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-981-4091
Mailing Address - Street 1:1200 N STATE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2001
Mailing Address - Country:US
Mailing Address - Phone:601-981-4091
Mailing Address - Fax:601-981-5039
Practice Address - Street 1:1026 BAPTIST CIR STE 400
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-2028
Practice Address - Country:US
Practice Address - Phone:601-981-4091
Practice Address - Fax:601-981-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207W00000X
207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSCA5305OtherRAILROAD MEDICARE
MS09014141Medicaid
MSC02080Medicare PIN