MEDICARE: MS. ERICA BROOKE EIDSON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	8296	GA

General Provider Information

NPI Number	:	1295276996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ERICA BROOKE EIDSON PA

Provider Business Mailing Address
First Line	:	1800 HOWELL MILL ROAD NW
Second Line	:	SUITE 450
City	:	ATLANTA
State	:	GA
Zip	:	30318-2508
Country	:	US
Telephone Number	:	404-355-4393
Fax Number	:	678-412-0086

Provider Business Practice Location Address
First Line	:	1800 HOWELL MILL ROAD NW
Second Line	:	SUITE 450
City	:	ATLANTA
State	:	GA
Zip	:	30318-2508
Country	:	US
Telephone Number	:	404-355-4393
Fax Number	:	678-412-0086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2017
Last Update Date	:	02/02/2018

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