Basic Information
| Provider Information | |||||||||
| NPI: | 1720161771 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EYE CARE SURGERY CENTER OF OLIVE BRANCH,LLC | ||||||||
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| 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 | ||||||||
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| AuthorizedOfficialLastName: | GOLLAMUDI | ||||||||
| AuthorizedOfficialFirstName: | SUBBA | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9016852200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| 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 |