Healthcare Provider Details

I. General information

NPI: 1043440530
Provider Name (Legal Business Name): FAMILY MEDICAL AND URGENT CARE CLINIC OF MCDONOUGH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2009
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 HWY 20 W
MCDONOUGH GA
30253-7311
US

IV. Provider business mailing address

1631 HWY 20 W
MCDONOUGH GA
30253-7311
US

V. Phone/Fax

Practice location:
  • Phone: 770-288-2822
  • Fax: 770-288-2820
Mailing address:
  • Phone: 770-288-2822
  • Fax: 770-288-2820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number056874
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004088
License Number StateGA

VIII. Authorized Official

Name: DANIELLE O EIDSON
Title or Position: ADMINISTRATIVE OPERATIONS MANAGER
Credential:
Phone: 770-288-2822