Provider Demographics
NPI:1649225517
Name:EAGLES LANDING OB GYN ASSOCIATES, PC
Entity Type:Organization
Organization Name:EAGLES LANDING OB GYN ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIVINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-474-1919
Mailing Address - Street 1:3333 JODECO RD STE D
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5319
Mailing Address - Country:US
Mailing Address - Phone:770-474-1919
Mailing Address - Fax:770-474-7832
Practice Address - Street 1:3333 JODECO RD STE D
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5319
Practice Address - Country:US
Practice Address - Phone:404-455-0110
Practice Address - Fax:770-474-7832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032893207V00000X
GA036810207V00000X
GA043639207V00000X
GA046612207V00000X
GA042399207V00000X
GA057739207V00000X
GA056295207V00000X
GA65352207V00000X
207V00000X
GARN070819 NP363LW0102X
GARN119659367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300033549AMedicaid
GA300033549AMedicaid