Provider Demographics
NPI:1780767673
Name:EYE CARE SURGERY CENTER OF SOUTHAVEN,LLC
Entity type:Organization
Organization Name:EYE CARE SURGERY CENTER OF SOUTHAVEN,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBBA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOLLAMUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-685-2200
Mailing Address - Street 1:825 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9411
Mailing Address - Country:US
Mailing Address - Phone:901-685-2200
Mailing Address - Fax:901-255-5631
Practice Address - Street 1:7600 AIRWAYS BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5138
Practice Address - Country:US
Practice Address - Phone:662-349-7477
Practice Address - Fax:662-349-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01022398Medicaid
MS01022398Medicaid