MEDICARE: GEORGIA EYE INSTITUTE, INC.

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
2	152W00000X	Optometrist

General Provider Information

NPI Number	:	1225106123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA EYE INSTITUTE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 931989
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31193-0001
Country	:	US
Telephone Number	:	912-756-6091
Fax Number	:	912-756-6098

Provider Business Practice Location Address
First Line	:	2429 HWY 17 SOUTH
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324
Country	:	US
Telephone Number	:	912-756-6091
Fax Number	:	912-756-6098

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT COORDINATOR
Name	:	ROBIN J. MADDOX
Credential	:
Telephone Number	:	912-350-9335

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	01/11/2008

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