Basic Information
| Provider Information | |||||||||
| NPI: | 1407929094 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAGLE PHYSICIANS AND ASSOCIATES PA | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EAGLE WALK-IN CLINIC AT GUILFORD COLLEGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14883 | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274154883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364822723 | ||||||||
| FaxNumber: | 3362943544 | ||||||||
| Practice Location | |||||||||
| Address1: | 603 A DOLLEY MADISON RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274104283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3364822723 | ||||||||
| FaxNumber: | 3362943544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 09/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | TERRI | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, EAGLE BUSINESS SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 3362683201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAGLE PHYSICIANS AND ASSOCIATES PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 011T0 | 01 | NC | BCBS OF NC | OTHER | 89011T0 | 05 | NC | MEDICAID |