Provider Demographics
NPI:1740407550
Name:EAGLES LANDING PEDIATRIC ASSOCIATES LLC
Entity Type:Organization
Organization Name:EAGLES LANDING PEDIATRIC ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERPHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LEARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-289-0103
Mailing Address - Street 1:1101 HOSPITAL DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9075
Mailing Address - Country:US
Mailing Address - Phone:678-289-0103
Mailing Address - Fax:678-289-0171
Practice Address - Street 1:1101 HOSPITAL DR
Practice Address - Street 2:SUITE 210
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9075
Practice Address - Country:US
Practice Address - Phone:678-289-0103
Practice Address - Fax:678-289-0171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040449261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care