Provider Demographics
NPI:1740276039
Name:BERG EYE CENTER, PC
Entity type:Organization
Organization Name:BERG EYE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:G
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-432-7012
Mailing Address - Street 1:2709 MEREDYTH DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-0222
Mailing Address - Country:US
Mailing Address - Phone:229-432-7012
Mailing Address - Fax:229-435-0211
Practice Address - Street 1:2709 MEREDYTH DR
Practice Address - Street 2:SUITE 110
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-0222
Practice Address - Country:US
Practice Address - Phone:229-432-7012
Practice Address - Fax:229-435-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021643207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55000157AMedicaid
GA1740276039Medicare PIN