=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144275017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE RETINA INSTITUTE, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2006
-----------------------------------------------------
Last Update Date | 09/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2701 N CAUSEWAY BLVD
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70002-6029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-455-0500
-----------------------------------------------------
Fax | 504-455-3730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2701 N CAUSEWAY BLVD
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70002-6029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-455-0500
-----------------------------------------------------
Fax | 504-455-3730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL PROVIDER
-----------------------------------------------------
Name | DR. SHEHAB A. EBRAHIM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 504-455-0500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 13621R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------