Provider Demographics
NPI:1710028287
Name:SOUTHERN RETINA LLC
Entity Type:Organization
Organization Name:SOUTHERN RETINA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-353-7900
Mailing Address - Street 1:5354 REYNOLDS ST
Mailing Address - Street 2:SUITE 317
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-6007
Mailing Address - Country:US
Mailing Address - Phone:912-353-7900
Mailing Address - Fax:
Practice Address - Street 1:5354 REYNOLDS ST
Practice Address - Street 2:SUITE 317
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6007
Practice Address - Country:US
Practice Address - Phone:912-353-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPA790Medicaid
GA00829551EMedicaid
GA18BDFVSMedicare PIN