=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609809326
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSISSIPPI EYE SURGERY CENTER UC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 08/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3432 BIENVILLE BLVD
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-244-0067
-----------------------------------------------------
Fax | 228-244-0071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3432 BIENVILLE BLVD
-----------------------------------------------------
City | OCEAN SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-244-0067
-----------------------------------------------------
Fax | 228-244-0071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. SANDY ROBERTSON
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 228-244-0067
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0900X
-----------------------------------------------------
Taxonomy Name | Amputee Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------