Provider Demographics
NPI:1104010594
Name:ROSWELL EYE CLINIC,INC
Entity Type:Organization
Organization Name:ROSWELL EYE CLINIC,INC
Other - Org Name:ROSWELL EYE CLINIC,INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOSCOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-992-7620
Mailing Address - Street 1:1190 GRIMES BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3930
Mailing Address - Country:US
Mailing Address - Phone:770-992-7620
Mailing Address - Fax:770-992-8262
Practice Address - Street 1:1190 GRIMES BRIDGE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3930
Practice Address - Country:US
Practice Address - Phone:770-992-7620
Practice Address - Fax:770-992-8262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA861-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00168583AMedicaid
GAU22197Medicare UPIN
U17445Medicare UPIN
GAU84370Medicare UPIN
GA00168583AMedicaid