NPIMap

Organization Active NPI

Marietta Eye Clinic, PA

  • Ophthalmology Physician
  • Cumming, GA
National Provider Identifier
1629784160
Registry record updated Mar 9, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Ophthalmology PhysicianTaxonomy code 207W00000X
Legal business name
MARIETTA EYE CLINIC, PA
Practice address
2860 Ronald Reagan Blvd Ste 210
Cumming, GA 30041-6092
Phone
(770) 427-8111
NPI assigned
Jan 27, 2023
Organization subpart
Yes
Parent organization
MARIETTA EYE CLINIC, PAAs reported in NPPES

Authorized official

NPPES NPI Registry
Name
Henry Elliott Gatehouse
Title
Director
Phone
(770) 427-8111

Other NPIs on the same Medicare enrollment 14

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

View all 14

Corporate family (same tax ID) 16

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

View all 16

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

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
11D2283729Marietta Eye Clinic, PA2860 Ronald Reagan Boulevard, Suite 210, Cumming, GA 30041Certificate of waiverJun 12, 2027

Medicare participation

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

Medicare enrollment records 1

Medicare enrollment files
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…

National Provider Directory

National Provider Directory
Tax ID family
Cartersville Eye Clinic (17 organizations share this tax ID)
Part of
Cartersville Eye Clinic

Locations

100 Old Ball Ground Hwy
Canton, GA 30114
Phone (770) 479-2195

895 Canton Rd NE
Marietta, GA 30060
Phone (678) 784-0203

Specialties & licenses 2

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
OptometristGroup: 193200000X MULTI-SPECIALTY GROUP 152W00000X
Ophthalmology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207W00000X Primary

Addresses

NPPES NPI Registry

Primary practice location

2860 Ronald Reagan Blvd Ste 210
Cumming, GA 30041-6092

Mailing address

895 Canton Rd NE
Marietta, GA 30060-8934
Phone (770) 427-8111

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Mar 9, 2023.

{
    "created_epoch": "1674777600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678320000000",
    "number": "1629784160",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "895 CANTON RD NE",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300608934",
            "telephone_number": "770-427-8111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2860 RONALD REAGAN BLVD STE 210",
            "city": "CUMMING",
            "state": "GA",
            "postal_code": "300416092",
            "telephone_number": "770-427-8111"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARIETTA EYE CLINIC, PA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MARIETTA EYE CLINIC, PA",
        "enumeration_date": "2023-01-27",
        "last_updated": "2023-03-09",
        "certification_date": "2023-03-09",
        "status": "A",
        "authorized_official_last_name": "GATEHOUSE",
        "authorized_official_first_name": "HENRY",
        "authorized_official_middle_name": "ELLIOTT",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "770-427-8111"
    },
    "taxonomies": [
        {
            "code": "152W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Optometrist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Ophthalmology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Cumming, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 9, 2023; 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.