Provider Demographics
NPI:1700039740
Name:GEORGIA EYE INSTITUTE OF THE SOUTHEAST, LLC
Entity Type:Organization
Organization Name:GEORGIA EYE INSTITUTE OF THE SOUTHEAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-629-5929
Mailing Address - Street 1:PO BOX 102635
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2635
Mailing Address - Country:US
Mailing Address - Phone:912-354-4800
Mailing Address - Fax:912-629-5821
Practice Address - Street 1:4720 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6292
Practice Address - Country:US
Practice Address - Phone:912-354-4800
Practice Address - Fax:912-629-5821
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA EYE INSTITUTE OF THE SOUTHEAST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-03
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDAG976OtherMEDICAID OD
SCGP5020OtherMEDICAID MD- BLUFFTON
SCGPA977OtherMEDICAID MD
SCDA9642OtherMEDICAID OD - BLUFFTON
SCDA9642OtherMEDICAID OD - BLUFFTON
SCGPA977OtherMEDICAID MD
GA511G701032Medicare PIN