Provider Demographics
NPI:1760467682
Name:SOUTHEAST RETINA CENTER PC
Entity Type:Organization
Organization Name:SOUTHEAST RETINA CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:706-210-0305
Mailing Address - Street 1:3685 WHEELER RD
Mailing Address - Street 2:STE 201
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909
Mailing Address - Country:US
Mailing Address - Phone:706-650-0061
Mailing Address - Fax:706-650-0064
Practice Address - Street 1:3685 WHEELER RD
Practice Address - Street 2:STE 201
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909
Practice Address - Country:US
Practice Address - Phone:706-650-0061
Practice Address - Fax:706-650-0064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPA 668Medicaid
GA000605283BMedicaid
GA000293719AMedicaid
GA000605283BMedicaid
GA000293719AMedicaid
GACM7112Medicare PIN
SCF459087472Medicare UPIN