Basic Information
| Provider Information | |||||||||
| NPI: | 1154555472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA RETINA SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 JOHNSON FERRY RD NE | ||||||||
| Address2: | SUITE 593 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042559096 | ||||||||
| FaxNumber: | 4042559097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 JOHNSON FERRY RD NE | ||||||||
| Address2: | SUITE 593 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042559096 | ||||||||
| FaxNumber: | 4042559097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2009 | ||||||||
| LastUpdateDate: | 04/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | LUCAS | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4042559096 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.