MEDICARE: MID SOUTH RETINA ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3104352	OTHER	TN	BLUE CROSS OF TENNESSEE
2	4067262	OTHER	TN	BLUE CROSS OF TENNESSEE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447286802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID SOUTH RETINA ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1000 DEPT 448
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38148-0448
Country	:	US
Telephone Number	:	731-427-7799
Fax Number	:	731-427-1476

Provider Business Practice Location Address
First Line	:	609 SKYLINE DR
Second Line	:
City	:	JACKSON
State	:	TN
Zip	:	38301-3911
Country	:	US
Telephone Number	:	731-427-7799
Fax Number	:	731-427-1476

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. WILLIAM PRIESTER
Credential	:	M.D.
Telephone Number	:	901-682-1100

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	08/05/2025

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