Provider Demographics
NPI:1871665448
Name:SOUTHERN VITREORETINAL ASSOCIATES, PL
Entity Type:Organization
Organization Name:SOUTHERN VITREORETINAL ASSOCIATES, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-942-6700
Mailing Address - Street 1:2439 CARE DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4580
Mailing Address - Country:US
Mailing Address - Phone:850-942-6700
Mailing Address - Fax:850-942-5735
Practice Address - Street 1:2439 CARE DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4580
Practice Address - Country:US
Practice Address - Phone:850-942-6700
Practice Address - Fax:850-942-5735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255289200Medicaid
AC743AMedicare PIN
GAGRP7991Medicare PIN
AC743Medicare PIN