Provider Demographics
NPI:1598120271
Name:EAGLES LANDING MEDICAL CENTER
Entity Type:Organization
Organization Name:EAGLES LANDING MEDICAL CENTER
Other - Org Name:MULTI SPECIALIST PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:SELENA
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-656-7203
Mailing Address - Street 1:1215 EAGLES LANDING PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7280
Mailing Address - Country:US
Mailing Address - Phone:770-389-9116
Mailing Address - Fax:
Practice Address - Street 1:1215 EAGLES LANDING PKWY STE 205
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7280
Practice Address - Country:US
Practice Address - Phone:770-389-9116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-22
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52394207N00000X
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1144255399OtherNPI NUMBER
GA1710213947Medicare PIN