Provider Demographics
NPI:1962846352
Name:AMEDCO GEORGIA LLC
Entity Type:Organization
Organization Name:AMEDCO GEORGIA LLC
Other - Org Name:TIFTON OPHTHALMOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERREIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-881-0022
Mailing Address - Street 1:8076 W SAHARA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7930
Mailing Address - Country:US
Mailing Address - Phone:877-881-0022
Mailing Address - Fax:702-543-0314
Practice Address - Street 1:1803 OLD OCILLA RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1617
Practice Address - Country:US
Practice Address - Phone:229-986-2181
Practice Address - Fax:229-386-2193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0774710001OtherCIGNA - GA
GACC4435OtherRR MEDICARE
GAGRP2612OtherMEDICARE