Provider Demographics
NPI:1285655464
Name:ATLANTA EYE INTERNATIONAL SURGERY CENTER INC.
Entity Type:Organization
Organization Name:ATLANTA EYE INTERNATIONAL SURGERY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-881-6417
Mailing Address - Street 1:830 W PEACHTREE ST NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1129
Mailing Address - Country:US
Mailing Address - Phone:404-881-6417
Mailing Address - Fax:404-876-7565
Practice Address - Street 1:830 W PEACHTREE ST NW
Practice Address - Street 2:SUITE 101
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1129
Practice Address - Country:US
Practice Address - Phone:404-881-6417
Practice Address - Fax:404-876-7565
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTA EYE CONSULTANT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-22
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11-C0001213261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00067521OtherRAILROAD MEDICARE
GA001796OtherBLUE CROSS BLUE SHIELD
GA681158897AMedicaid
GA681158897AMedicaid
GA111213ASCAMedicare ID - Type Unspecified