VisionSouth, P.C.

Contacts

Phone	+1 205-879-2221
Fax	2058790615

Authorized person

Name	MR. CHARLES MICHAEL ADAMS
Role	PRESIDENT/OWNER
Phone	2058792221

Taxonomy

Taxonomy Code	207W00000X - Ophthalmology Physician
License Number	15436
State	AL
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	000088561
State	AL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1992-01-02
Business code	621111
Sponsor’s telephone number	2058792221
Plan sponsor’s address	470 BOTANICAL PLACE, BIRMINGHAM, AL, 35223

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1992-01-02
Business code	621111
Sponsor’s telephone number	2058792221
Plan sponsor’s address	2700 HIGHWAY 280 EAST, SUITE 212, BIRMINGHAM, AL, 35223

Signature of

Role	Plan administrator
Date	2015-01-30
Name of individual signing	MIKE PALMER

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1992-01-02
Business code	621111
Sponsor’s telephone number	2058792221
Plan sponsor’s address	2700 HIGHWAY 280 EAST, SUITE 212, BIRMINGHAM, AL, 35223

Signature of

Role	Plan administrator
Date	2014-05-15
Name of individual signing	C. MICHAEL ADAMS

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1992-01-02
Business code	621111
Sponsor’s telephone number	2058792221
Plan sponsor’s address	2700 HIGHWAY 280 EAST, SUITE 212, BIRMINGHAM, AL, 35223

Plan administrator’s name and address

Administrator’s EIN	631057313
Plan administrator’s name	VISIONSOUTH, P.C.
Plan administrator’s address	2700 HIGHWAY 280 EAST, SUITE 212, BIRMINGHAM, AL, 35223
Administrator’s telephone number	2058792221

Signature of

Role	Plan administrator
Date	2013-03-20
Name of individual signing	CARL HELTON