Provider Demographics
NPI:1558415232
Name:EGLESTON PEDATRIC GROUP
Entity Type:Organization
Organization Name:EGLESTON PEDATRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:LOUETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-785-7876
Mailing Address - Street 1:1584 TULLIE CIR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2311
Mailing Address - Country:US
Mailing Address - Phone:404-785-7928
Mailing Address - Fax:
Practice Address - Street 1:2620 SATELLITE BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1204
Practice Address - Country:US
Practice Address - Phone:404-785-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty