Provider Demographics
NPI:1861517054
Name:SLIDELL EYE SPECIALISTS, APMC
Entity type:Organization
Organization Name:SLIDELL EYE SPECIALISTS, APMC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-249-0206
Mailing Address - Street 1:2050 GAUSE BLVD E STE 150
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-5414
Mailing Address - Country:US
Mailing Address - Phone:985-649-0206
Mailing Address - Fax:985-649-4060
Practice Address - Street 1:2050 GAUSE BLVD E STE 150
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-5414
Practice Address - Country:US
Practice Address - Phone:985-649-0206
Practice Address - Fax:985-649-4060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1940682Medicaid
CC9303OtherRAILROAD MEDICARE
MS9013659Medicaid
=========OtherGROUP TAX ID
LA57823Medicare ID - Type Unspecified