Basic Information
| Provider Information | |||||||||
| NPI: | 1699729806 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VRF EYE SPECIALTY GROUP, PLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VITREORETINAL FOUNDATION | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 825 RIDGE LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016852200 | ||||||||
| FaxNumber: | 9018202342 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 RIDGE LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016852200 | ||||||||
| FaxNumber: | 9018202342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOLLAMUDI | ||||||||
| AuthorizedOfficialFirstName: | SUBBA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9016852200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 364S00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 09015167 | 05 | MS | MEDICAID | 127952002 | 05 | AR | MEDICAID | 3383289 | 05 | TN | MEDICAID | 506916204 | 05 | MO | MEDICAID |