Provider Demographics
NPI:1245563352
Name:EAGLE MEDICAL CENTER
Entity Type:Organization
Organization Name:EAGLE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GBENGA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALUKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-975-6004
Mailing Address - Street 1:PO BOX 667889
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28266-7889
Mailing Address - Country:US
Mailing Address - Phone:704-926-5434
Mailing Address - Fax:704-454-7388
Practice Address - Street 1:1951 OLD STEELE CREEK ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5631
Practice Address - Country:US
Practice Address - Phone:704-926-5434
Practice Address - Fax:704-454-7388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-09
Last Update Date:2009-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01333207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14096OtherBLUECROSS BLUSHIELD
NC5902507Medicaid
SC278746Medicaid
SC278746Medicaid