Retina Specialists of Alabama in Montgomery, LLC

Business Information

Congressional District	02
State/Country of Incorporation	AL, USA
Activation Date	2022-01-10
Initial Registration Date	2021-01-04
Entity Start Date	2000-04-10
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	+1 205-933-2625
Fax	2055582553
Phone	+1 334-263-0105
Fax	3342644386

Authorized person

Name	MICHAEL PAIGE MASSEY
Role	MANAGING PHYSCIAN
Phone	3342630105

Taxonomy

Taxonomy Code	207W00000X - Ophthalmology Physician
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	1851336226
State	AL

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DR SUITE 314, MONTGOMERY, AL, 36111

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DR SUITE 314, MONTGOMERY, AL, 36111

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DR SUITE 314, MONTGOMERY, AL, 36111

Signature of

Role	Plan administrator
Date	2022-05-18
Name of individual signing	JEFF DANCE

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DR SUITE 314, MONTGOMERY, AL, 36111

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	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DR SUITE 314, MONTGOMERY, AL, 36111

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DR SUITE 314, MONTGOMERY, AL, 36111

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DR SUITE 314, MONTGOMERY, AL, 36111

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DR SUITE 314, MONTGOMERY, AL, 36111

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DR SUITE 314, MONTGOMERY, AL, 36111

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	2007-01-01
Business code	621111
Sponsor’s telephone number	3342630105
Plan sponsor’s address	2055 NORMANDIE DRIVE, SUITE 314, MONTGOMERY, AL, 36111

Plan administrator’s name and address

Administrator’s EIN	631248339
Plan administrator’s name	RETINA SPECIALISTS OF ALABAMA IN MONTGOMERY, LLC
Plan administrator’s address	2055 NORMANDIE DRIVE, SUITE 314, MONTGOMERY, AL, 36111
Administrator’s telephone number	3342630105

Signature of

Role	Plan administrator
Date	2015-07-29
Name of individual signing	MICHAEL MASSEY