Provider Demographics
NPI:1427261759
Name:PREMIER OPHTHALMOLOGY LLC
Entity type:Organization
Organization Name:PREMIER OPHTHALMOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-787-6200
Mailing Address - Street 1:7170 HIGHWAY 278 NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-1529
Mailing Address - Country:US
Mailing Address - Phone:770-787-6200
Mailing Address - Fax:770-787-2643
Practice Address - Street 1:7170 HIGHWAY 278 NE
Practice Address - Street 2:SUITE B
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1529
Practice Address - Country:US
Practice Address - Phone:770-787-6200
Practice Address - Fax:770-787-2643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027835207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3146Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER