MEDICARE: EAST POINT EYE CLINIC PC

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	156FX1100X	Ophthalmic Technician/Technologist	45207	GA

General Provider Information

NPI Number	:	1801059175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST POINT EYE CLINIC PC

Provider Business Mailing Address
First Line	:	3995 RANDALL MILL RD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30327-3101
Country	:	US
Telephone Number	:	404-346-2020
Fax Number	:	404-346-2026

Provider Business Practice Location Address
First Line	:	3600 MARKETPLACE BLVD
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-8129
Country	:	US
Telephone Number	:	404-346-2020
Fax Number	:	404-346-2026

Authorized Official
Title or Position	:	OPHTHALMOLOGY
Name	:	DR. INGRID A ELLISON
Credential	:	M.D.
Telephone Number	:	404-346-2020

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	07/08/2008

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