Basic Information
Provider Information | |||||||||
NPI: | 1750455952 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EGLESTON AFFILIATED SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHILDREN'S HEALTHCARE OF ATLANTA AT WEST COBB | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1584 TULLIE CIR NE | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303292311 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047857928 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2041 MESA VALLEY WAY | ||||||||
Address2: | SUITE 185 | ||||||||
City: | AUSTELL | ||||||||
State: | GA | ||||||||
PostalCode: | 30106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047858900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMAS | ||||||||
AuthorizedOfficialFirstName: | TOBY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, MANAGED CARE | ||||||||
AuthorizedOfficialTelephone: | 4047858900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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.