Basic Information
| Provider Information | |||||||||
| NPI: | 1306877261 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST ALABAMA EYE SURGERY CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHEAST AL EYE SURGERY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8567 | ||||||||
| Address2: | |||||||||
| City: | GADSDEN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359028567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565478634 | ||||||||
| FaxNumber: | 2565473039 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | GADSDEN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359014224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565478634 | ||||||||
| FaxNumber: | 2565473039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 07/17/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2565478634 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 5650 | AL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | ASC0068C | 05 | AL | MEDICAID |