Provider Demographics
NPI:1932207669
Name:EYE SURGICAL CENTER OF MISSISSIPPI
Entity Type:Organization
Organization Name:EYE SURGICAL CENTER OF MISSISSIPPI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:BRANNON
Authorized Official - Last Name:ADEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-969-1430
Mailing Address - Street 1:1053 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9595
Mailing Address - Country:US
Mailing Address - Phone:601-969-1430
Mailing Address - Fax:601-709-2117
Practice Address - Street 1:1053 RIVER OAKS DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9595
Practice Address - Country:US
Practice Address - Phone:601-969-1430
Practice Address - Fax:601-709-2117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03482026Medicaid
MS=========OtherTAX IDENTIFICATION NUMBER
MS=========OtherTAX IDENTIFICATION NUMBER
MS490000060Medicare ID - Type Unspecified