Provider Demographics
NPI:1629120928
Name:SOUTHEAST EYE SURGERY CENTER, PC
Entity Type:Organization
Organization Name:SOUTHEAST EYE SURGERY CENTER, PC
Other - Org Name:OMNI EYE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:5505 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1705
Mailing Address - Country:US
Mailing Address - Phone:404-257-0814
Mailing Address - Fax:404-843-8521
Practice Address - Street 1:5505 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 300
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1705
Practice Address - Country:US
Practice Address - Phone:404-257-0814
Practice Address - Fax:404-843-8521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty