Provider Demographics
NPI:1376610618
Name:AMERICAN EYECARE CENTER OF JESUP INC
Entity Type:Organization
Organization Name:AMERICAN EYECARE CENTER OF JESUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DERRYL
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:912-530-6000
Mailing Address - Street 1:198 SW BROAD ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-1101
Mailing Address - Country:US
Mailing Address - Phone:912-530-6000
Mailing Address - Fax:912-530-6044
Practice Address - Street 1:198 SW BROAD ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-1101
Practice Address - Country:US
Practice Address - Phone:912-530-6000
Practice Address - Fax:912-530-6044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00461876BMedicaid
GA00461876DMedicaid
GA410026823OtherRAILROAD MEDICARE
GA41ZCBQWMedicare PIN
GAGRP1517Medicare PIN
GA00461876DMedicaid
GA410026823OtherRAILROAD MEDICARE