Provider Demographics
NPI:1750981189
Name:SOUTHEAST EYE SPECIALISTS, PLLC
Entity type:Organization
Organization Name:SOUTHEAST EYE SPECIALISTS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CRUDUP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-0450
Mailing Address - Street 1:341 COOL SPRINGS BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-7224
Mailing Address - Country:US
Mailing Address - Phone:615-349-8965
Mailing Address - Fax:
Practice Address - Street 1:9453 DAYTON PIKE
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-4751
Practice Address - Country:US
Practice Address - Phone:423-508-7337
Practice Address - Fax:423-508-7338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST EYE SPECIALISTS, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-26
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3721447OtherMEDICARE PIN
GA524169578AMedicaid
GRP6156OtherMEDICARE PIN