Basic Information
| Provider Information | |||||||||
| NPI: | 1568403921 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAGLES LANDING FAMILY PRACTICE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1058 BEAR CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302281849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707070808 | ||||||||
| FaxNumber: | 7707071580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1058 BEAR CREEK BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302281849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707070808 | ||||||||
| FaxNumber: | 7707071580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | MITCHAM | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7709140116 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CC6012 | 01 | GA | RAILROAD MEDICARE | OTHER | 061407 | 01 | GA | BC/BS OF GA GROUP | OTHER |