Provider Demographics
NPI:1194988220
Name:EYE SURGERY CENTER OF ALBANY, LLC
Entity type:Organization
Organization Name:EYE SURGERY CENTER OF ALBANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
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:229-435-8799
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:229-435-8799
Mailing Address - Fax:229-438-8345
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:229-435-8799
Practice Address - Fax:229-438-8345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047-325261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP8066Medicare PIN
GAP00286475Medicare PIN