1144474016 NPI number — GEORGIA EYE INSTITUTE OF THE SOUTHEAST, LLC

Table of content: (NPI 1144474016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144474016 NPI number — GEORGIA EYE INSTITUTE OF THE SOUTHEAST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA EYE INSTITUTE OF THE SOUTHEAST, LLC
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:
1144474016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4720 WATERS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31404-6292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-354-4800
Provider Business Mailing Address Fax Number:
912-629-5821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6162 HWY 21 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RINCON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31326-5164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-826-3949
Provider Business Practice Location Address Fax Number:
912-826-0389
Provider Enumeration Date:
11/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HEGAN
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
912-629-5929

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: DAG976 . This is a "MEDICAID OD" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GPA977 . This is a "MEDICAID MD" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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