Provider Demographics
NPI:1932200664
Name:SOUTHEASTERN RETINA ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:SOUTHEASTERN RETINA ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVERGHETTA
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:865-588-0811
Mailing Address - Street 1:9050 EXECUTIVE PARK DR STE 202A
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4670
Mailing Address - Country:US
Mailing Address - Phone:423-756-1512
Mailing Address - Fax:865-934-3884
Practice Address - Street 1:1124 E WEISGARBER RD
Practice Address - Street 2:SUITE 207
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2686
Practice Address - Country:US
Practice Address - Phone:865-588-0811
Practice Address - Fax:865-584-2153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207W00000X
207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACG2897OtherRAILROAD MEDICARE
TNCL1229OtherRAILROAD MEDICARE
TNCD7808OtherRAILROAD MEDICARE
TN3850174Medicaid
VAC06221Medicare PIN
TNCD7808OtherRAILROAD MEDICARE
VACG2897OtherRAILROAD MEDICARE