Basic Information
| Provider Information | |||||||||
| NPI: | 1043384241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EGLESTON AFFILIATED SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDREN'S HEALTHCARE OF ATLANTA AT NORTHPOINT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1584 TULLIE CIR NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3795 MANSELL RD | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300228247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857928 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | TOBY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 4047857914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 044-079 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.