Basic Information
| Provider Information | |||||||||
| NPI: | 1841375896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST ALABAMA EYE CLINIC OF ANNISTON, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1029 CHRISTINE AVE | ||||||||
| Address2: | |||||||||
| City: | ANNISTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362075709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562370371 | ||||||||
| FaxNumber: | 2562364181 | ||||||||
| Practice Location | |||||||||
| Address1: | 1029 CHRISTINE AVE | ||||||||
| Address2: | |||||||||
| City: | ANNISTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 362075709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562370371 | ||||||||
| FaxNumber: | 2562364181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | KEYS | ||||||||
| AuthorizedOfficialFirstName: | KENT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 2562370371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 528601110 | 05 | AL | MEDICAID |