NPIMap

Organization Active NPI

Marietta Eye Clinic, PA

  • Ophthalmology Physician
  • Woodstock, GA
National Provider Identifier
1063933588
Registry record updated May 15, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
Legal business name
MARIETTA EYE CLINIC, PA
Practice address
2990 Eagle Dr Ste 110
Woodstock, GA 30189
Phone
(770) 427-8111
NPI assigned
Jul 6, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 15, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Henry Elliott Gatehouse
Title
Senior Director
Phone
(770) 427-8111

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 152W00000X
Ophthalmology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207W00000X Primary

Addresses

Primary practice location

2990 Eagle Dr Ste 110
Woodstock, GA 30189

Mailing address

895 Canton Rd NE BLDG 100
Marietta, GA 30060-8935

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040518000057 GA Part B Supplier - Clinic/Group Practice 0143210427 Receives reassigned benefits from 46 practitioners
14 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Woodstock, GA; Villa Rica, GA; Suwanee, GA; Roswell, GA; Marietta, GA; Acworth, GA; Canton, GA; Cartersville, GA…

Other NPIs on the same Medicare enrollment 14

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 14

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2135810Marietta Eye Clinic, PA2990 Eagle Drive, Suite 110, Woodstock, GA 30189Certificate of waiverAug 28, 2027

National Provider Directory

National Provider Directory
Tax ID family
Cartersville Eye Clinic17 organizations share this tax ID, including this one

Other organizations with this tax ID 16

Organizations that report the same tax identification number in the National Provider Directory.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1499299200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1526342400000",
    "number": "1063933588",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "895 CANTON RD NE BLDG 100",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300608935"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2990 EAGLE DR STE 110",
            "city": "WOODSTOCK",
            "state": "GA",
            "postal_code": "30189",
            "telephone_number": "770-427-8111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARIETTA EYE CLINIC, PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-07-06",
        "last_updated": "2018-05-15",
        "status": "A",
        "authorized_official_last_name": "GATEHOUSE",
        "authorized_official_first_name": "HENRY",
        "authorized_official_middle_name": "ELLIOTT",
        "authorized_official_title_or_position": "SENIOR DIRECTOR",
        "authorized_official_telephone_number": "770-427-8111"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Ophthalmology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Woodstock, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 15, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.