Provider Demographics
NPI:1922007525
Name:SCOT A. WALL, MD, PC
Entity Type:Organization
Organization Name:SCOT A. WALL, MD, PC
Other - Org Name:WALL EYE CARE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-888-2395
Mailing Address - Street 1:2308 PALMYRA RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1324
Mailing Address - Country:US
Mailing Address - Phone:229-888-2395
Mailing Address - Fax:
Practice Address - Street 1:2308 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1324
Practice Address - Country:US
Practice Address - Phone:229-888-2395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-18
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55000513AMedicaid
GA55000513AMedicaid
GAGRP537Medicare ID - Type Unspecified
0749880001Medicare NSC
0749880001Medicare PIN