Provider Demographics
NPI:1578630794
Name:TED A MCELROY OD, PC
Entity Type:Organization
Organization Name:TED A MCELROY OD, PC
Other - Org Name:VISION SOURCE TIFTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TED
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCELROY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:229-382-4765
Mailing Address - Street 1:PO BOX 1186
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-1186
Mailing Address - Country:US
Mailing Address - Phone:229-382-4765
Mailing Address - Fax:229-382-4819
Practice Address - Street 1:2012 PINEVIEW AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3035
Practice Address - Country:US
Practice Address - Phone:229-382-4765
Practice Address - Fax:229-382-4819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1397152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA410029773OtherMEDICARE RAILROAD
GA300031267AMedicaid
GAGRP4593Medicare ID - Type Unspecified
GA1088970001Medicare NSC
GA300031267AMedicaid