Provider Demographics
NPI:1912187618
Name:SOUTHERN EYE ASSOCIATES OF GA LLC
Entity Type:Organization
Organization Name:SOUTHERN EYE ASSOCIATES OF GA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTUS
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-265-2020
Mailing Address - Street 1:340 BOULEVARD NE
Mailing Address - Street 2:SUITE 318
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1273
Mailing Address - Country:US
Mailing Address - Phone:404-265-2020
Mailing Address - Fax:
Practice Address - Street 1:340 BOULEVARD NE
Practice Address - Street 2:SUITE 318
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1273
Practice Address - Country:US
Practice Address - Phone:404-265-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA180046095OtherMEDICARE RAILROAD
GA182460432823OtherHUMANA
GA00093221COtherPEACHSTATE
GA309318OtherWELLCARE
GA1003900OtherAMERIGROUP
GA309318OtherWELLCARE
GA180046095OtherMEDICARE RAILROAD