Basic Information
| Provider Information | |||||||||
| NPI: | 1235343807 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA EYE INSTITUTE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 931989 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311930001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123504800 | ||||||||
| FaxNumber: | 9123504821 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125372020 | ||||||||
| FaxNumber: | 9123504821 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MADDOX | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9123509335 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | GA | X | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | GA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.