1629165642 NPI number — GEORGIA EYE ASSOCIATES, P.C.

Table of content: (NPI 1629165642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629165642 NPI number — GEORGIA EYE ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA EYE ASSOCIATES, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629165642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
771 OLD NORCROSS RD
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30046-4979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-995-5408
Provider Business Mailing Address Fax Number:
770-513-2042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
771 OLD NORCROSS RD
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30046-4979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-995-5408
Provider Business Practice Location Address Fax Number:
770-513-2042
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POLAND
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
770-995-5408

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT001207 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OPT001163 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OPT002167 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 031101 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X , with the licence number: 050167 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 021751 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CG1368 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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