Provider Demographics
NPI:1902201254
Name:TIPPETT EYECARE, PC
Entity type:Organization
Organization Name:TIPPETT EYECARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-738-1102
Mailing Address - Street 1:2465 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6244
Mailing Address - Country:US
Mailing Address - Phone:706-738-1102
Mailing Address - Fax:
Practice Address - Street 1:701 DEVIKA DR STE 3
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5137
Practice Address - Country:US
Practice Address - Phone:762-222-7104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-29
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1296T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000618549AMedicaid
GA1213300002OtherDMERC
GAU34631Medicare UPIN