Provider Demographics
NPI:1447286802
Name:MID-SOUTH RETINA ASSOCIATES, LLC
Entity type:Organization
Organization Name:MID-SOUTH RETINA ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEVERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-682-1100
Mailing Address - Street 1:PO BOX 1000 DEPT 448
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0448
Mailing Address - Country:US
Mailing Address - Phone:731-427-7799
Mailing Address - Fax:731-427-1476
Practice Address - Street 1:609 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3911
Practice Address - Country:US
Practice Address - Phone:731-427-7799
Practice Address - Fax:731-427-1476
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MID-SOUTH RETINA ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-25
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3886759Medicaid
TN4067262OtherBLUE CROSS OF TENNESSEE
TN3812364Medicaid
TN3104352OtherBLUE CROSS OF TENNESSEE
TN3812364Medicaid
TN3104352OtherBLUE CROSS OF TENNESSEE
TN3387048Medicare PIN
TN3886759Medicaid