=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356497747
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACON EYE SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 12/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 864 1ST STREET
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31201-6875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-741-6522
-----------------------------------------------------
Fax | 478-745-2887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6908
-----------------------------------------------------
City | WARNER ROBINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31095-6908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-741-1740
-----------------------------------------------------
Fax | 478-745-2887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | ALISHA STONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-551-4642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------