Basic Information
| Provider Information | |||||||||
| NPI: | 1003896952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAVELLANA | ||||||||
| FirstName: | EILEEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705334786 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782074373 | ||||||||
| FaxNumber: | 7705334727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RB0002X | 045841 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine | 208M00000X | 045841 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 045841 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110029C048846 | 01 | GA | TRAILBLAZER HEALTH ENTERPRISES | OTHER | 11BDRZS | 01 | GA | MEDICARE CAHABA GBA | OTHER | 000800555B | 05 | GA | MEDICAID | 000800555D | 05 | GA | MEDICAID | 000800555H | 05 | GA | MEDICAID | 000800555N | 05 | GA | MEDICAID | 783517 | 01 | GA | ATENA | OTHER | 2448449 | 01 | GA | CIGNA | OTHER | 000800555I | 05 | GA | MEDICAID | 10045921 | 01 | GA | AMERIGROUP | OTHER | 582117020 | 01 | GA | TRICARE CERTIFIED | OTHER | 582117020045 | 01 | GA | TRICARE CERTIFIED | OTHER | 000800555C | 05 | GA | MEDICAID | 110211686 | 01 | GA | RR MEDICARE-GRP # CC4177 | OTHER | 582117020057 | 01 | GA | TRICARE CERTIFIED | OTHER | 767999 | 01 | GA | COVENTRY HEALTHCARE | OTHER | 000800555F | 05 | GA | MEDICAID | 000800555K | 05 | GA | MEDICAID | 000800555M | 05 | GA | MEDICAID | 110211686 | 01 | GA | PALMETTO RAILROAD MEDICARE PART B | OTHER | 52598478 | 01 | GA | BCBS | OTHER | 000800555J | 05 | GA | MEDICAID | 0400503 | 01 | GA | UNITED HEALTHCARE | OTHER | 340854 | 01 | GA | WELLCARE | OTHER | 000800555E | 05 | GA | MEDICAID | 000800555G | 05 | GA | MEDICAID | 000800555L | 05 | GA | MEDICAID | 582117020055 | 01 | GA | TRICARE CERTIFIED | OTHER |