Provider Demographics
NPI:1902907207
Name:EAGLES LANDING FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:EAGLES LANDING FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-914-0116
Mailing Address - Street 1:62 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6012
Mailing Address - Country:US
Mailing Address - Phone:770-914-0116
Mailing Address - Fax:770-914-7703
Practice Address - Street 1:62 KELLY RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6012
Practice Address - Country:US
Practice Address - Phone:770-914-0116
Practice Address - Fax:770-914-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA29378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA061407OtherBC/BS OF GA GROUP
GACC6012OtherRAILROAD MEDICARE
GACC6012OtherRAILROAD MEDICARE