Provider Demographics
NPI:1841483427
Name:EAG PROFESSIONAL MEDICAL CORP.
Entity type:Organization
Organization Name:EAG PROFESSIONAL MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELEUTERIO
Authorized Official - Middle Name:ARCANGEL
Authorized Official - Last Name:GO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-537-4434
Mailing Address - Street 1:3512 HILLGLEN AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-7867
Mailing Address - Country:US
Mailing Address - Phone:209-985-4813
Mailing Address - Fax:209-551-3255
Practice Address - Street 1:1809 CENTRAL AVE STE C
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-1806
Practice Address - Country:US
Practice Address - Phone:209-537-4434
Practice Address - Fax:209-551-3255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA682962084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A682962OtherMEDICARE PPIN
CA6213236Medicaid
CAZZZ01404ZOtherMEDICARE GROUP ID
CAG65869Medicare UPIN
CA6213236Medicaid