Provider Demographics
NPI:1265995401
Name:EAGAN MEDICAL GROUP INC
Entity type:Organization
Organization Name:EAGAN MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BREANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-369-8037
Mailing Address - Street 1:8140 N MOPAC EXPY STE 150
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8837
Mailing Address - Country:US
Mailing Address - Phone:337-665-6138
Mailing Address - Fax:
Practice Address - Street 1:8140 N MOPAC EXPY STE 150
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8837
Practice Address - Country:US
Practice Address - Phone:833-766-5613
Practice Address - Fax:512-535-1413
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAGAN MEDICAL GROUP OF TEXAS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-12
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG67163OtherMEDICAL LICENSE