Provider Demographics
NPI:1841383122
Name:ADVANCED EYECARE OF GEORGIA PC
Entity Type:Organization
Organization Name:ADVANCED EYECARE OF GEORGIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BALDWIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:770-233-6860
Mailing Address - Street 1:1118 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4937
Mailing Address - Country:US
Mailing Address - Phone:770-233-6860
Mailing Address - Fax:
Practice Address - Street 1:1569 N EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-1746
Practice Address - Country:US
Practice Address - Phone:770-233-6860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-01
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA819T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55413554SAMedicaid
GA55413554SAMedicaid