Provider Demographics
NPI:1013963719
Name:GENESIS EYE CENTER
Entity Type:Organization
Organization Name:GENESIS EYE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-295-0001
Mailing Address - Street 1:817 EAST MOREHEAD STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2767
Mailing Address - Country:US
Mailing Address - Phone:704-295-0001
Mailing Address - Fax:704-295-0002
Practice Address - Street 1:817 EAST MOREHEAD STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2767
Practice Address - Country:US
Practice Address - Phone:704-295-0001
Practice Address - Fax:704-295-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891024YMedicaid
G32353Medicare UPIN
NC2349921Medicare ID - Type Unspecified