Provider Demographics
NPI:1629259395
Name:UPSON EYE CLINIC
Entity Type:Organization
Organization Name:UPSON EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-647-8138
Mailing Address - Street 1:232 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3402
Mailing Address - Country:US
Mailing Address - Phone:706-647-8138
Mailing Address - Fax:706-647-8745
Practice Address - Street 1:232 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3402
Practice Address - Country:US
Practice Address - Phone:706-647-8138
Practice Address - Fax:706-647-8745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048999207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACB6575OtherRAILROAD MEDICARE
GA000896695AMedicaid
GA000896695AMedicaid
GA18BDFTKMedicare PIN
GACB6575OtherRAILROAD MEDICARE