Basic Information
Provider Information | |||||||||
NPI: | 1720161771 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EYE CARE SURGERY CENTER OF OLIVE BRANCH,LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 825 RIDGE LAKE BLVD | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381209411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9016852200 | ||||||||
FaxNumber: | 9012555631 | ||||||||
Practice Location | |||||||||
Address1: | 6947 CRUMPLER BLVD | ||||||||
Address2: | SUITE 105 | ||||||||
City: | OLIVE BRANCH | ||||||||
State: | MS | ||||||||
PostalCode: | 386541922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6628933305 | ||||||||
FaxNumber: | 6628933306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/23/2006 | ||||||||
LastUpdateDate: | 07/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOLLAMUDI | ||||||||
AuthorizedOfficialFirstName: | SUBBA | ||||||||
AuthorizedOfficialMiddleName: | R. | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9016852200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 07/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 03058373 | 05 | MS |   | MEDICAID |