Provider Demographics
NPI:1043304215
Name:GREENSBORO OPHTHALMOLOGY ASSOC PA
Entity type:Organization
Organization Name:GREENSBORO OPHTHALMOLOGY ASSOC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:336-274-4626
Mailing Address - Street 1:8 N POINTE CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-3187
Mailing Address - Country:US
Mailing Address - Phone:336-274-4626
Mailing Address - Fax:336-274-7952
Practice Address - Street 1:8 N POINTE CT
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-3187
Practice Address - Country:US
Practice Address - Phone:336-274-4626
Practice Address - Fax:336-274-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCD4787OtherRR MEDICARE
NC230390Medicare PIN