Provider Demographics
NPI:1518162445
Name:SOUTHERN EYE ASSOCIATES, PA
Entity Type:Organization
Organization Name:SOUTHERN EYE ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-571-0081
Mailing Address - Street 1:2801 BLUE RIDGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6474
Mailing Address - Country:US
Mailing Address - Phone:919-571-0081
Mailing Address - Fax:
Practice Address - Street 1:2801 BLUE RIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6474
Practice Address - Country:US
Practice Address - Phone:919-571-0081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0048261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00652OtherBCBS ASC
NC3409867Medicaid
NC490001936OtherRAILROAD MED ASC
NC490001936OtherRAILROAD MED ASC