Healthcare Provider Details

I. General information

NPI: 1639246770
Provider Name (Legal Business Name): GEORGIA EYE INSTITUTE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 GA HIGHWAY 119 S
SPRINGFIELD GA
31329-3021
US

IV. Provider business mailing address

PO BOX 931989
ATLANTA GA
31193-0001
US

V. Phone/Fax

Practice location:
  • Phone: 912-754-1726
  • Fax: 912-754-2337
Mailing address:
  • Phone: 912-754-1726
  • Fax: 912-754-2337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBIN J. MADDOX
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 912-350-9335