Provider Demographics
NPI:1932272663
Name:AMERICAN MEDICAL SYSTEMS INC
Entity type:Organization
Organization Name:AMERICAN MEDICAL SYSTEMS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NORRIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:478-741-3697
Mailing Address - Street 1:PO BOX 2827
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31203
Mailing Address - Country:US
Mailing Address - Phone:478-741-3697
Mailing Address - Fax:478-750-1474
Practice Address - Street 1:1745 CLINTON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1721
Practice Address - Country:US
Practice Address - Phone:478-741-3697
Practice Address - Fax:478-750-1474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
GAPHRE008163333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000224892AMedicaid
GA000224892AMedicaid