Provider Demographics
NPI:1780820381
Name:SEASIDE SURGICAL, LLC
Entity Type:Organization
Organization Name:SEASIDE SURGICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-466-9500
Mailing Address - Street 1:3303B GLYNN AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4406
Mailing Address - Country:US
Mailing Address - Phone:912-466-9500
Mailing Address - Fax:912-466-9922
Practice Address - Street 1:3303B GLYNN AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4406
Practice Address - Country:US
Practice Address - Phone:912-466-9500
Practice Address - Fax:912-466-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-02
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11C0001332OtherMEDICARE
GA833908673AMedicaid