Retina Specialists of West Alabama, LLC

Business Information

Congressional District	07
State/Country of Incorporation	AL, USA
Activation Date	2022-01-11
Initial Registration Date	2021-01-04
Entity Start Date	2006-09-08
Fiscal Year End Close Date	Dec 31

Points of Contacts

Electronic Business
Title	PRIMARY POC
Name	JESSICA BAKANE
Address	2101 HIGHLAND AVENUE, SUITE 350, BIRMINGHAM, AL, 35205, USA

Government Business
Title	PRIMARY POC
Name	JESSICA BAKANE
Address	2101 HIGHLAND AVENUE, SUITE 350, BIRMINGHAM, AL, 35205, USA

Past Performance	Information not Available

Contacts

Phone	+1 205-558-2525
Fax	2055582554
Phone	+1 205-343-0003
Fax	2053430029

Authorized person

Name	SAMUEL WAYNE TAYLOR JR.
Role	MEMBER
Phone	2053430003

Taxonomy

Taxonomy Code	207WX0107X - Retina Specialist (Ophthalmology) Physician
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	529931100
State	AL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

Signature of

Role	Plan administrator
Date	2021-09-29
Name of individual signing	JEFF DANCE

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

Plan administrator’s name and address

Administrator’s EIN	205497340
Plan administrator’s name	RETINA SPECIALISTS OF WEST ALABAMA, LLC
Plan administrator’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401
Administrator’s telephone number	8882279182

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

Plan administrator’s name and address

Administrator’s EIN	205497340
Plan administrator’s name	RETINA SPECIALISTS OF WEST ALABAMA, LLC
Plan administrator’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401
Administrator’s telephone number	8882279182

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-03-01
Business code	621111
Sponsor’s telephone number	8882279182
Plan sponsor’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401

Plan administrator’s name and address

Administrator’s EIN	205497340
Plan administrator’s name	RETINA SPECIALISTS OF WEST ALABAMA, LLC
Plan administrator’s address	500 HARGROVE ROAD EAST, TUSCALOOSA, AL, 35401
Administrator’s telephone number	8882279182

Signature of

Role	Plan administrator
Date	2015-07-29
Name of individual signing	WAYNE TAYLOR, M.D.