Healthcare Provider Details

I. General information

NPI: 1821288754
Provider Name (Legal Business Name): EAGLES LANDING PRIMARY CARE SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 S COBB DR SE SUITE 103
SMYRNA GA
30080-7809
US

IV. Provider business mailing address

3001 S COBB DR SE SUITE 103
SMYRNA GA
30080-7809
US

V. Phone/Fax

Practice location:
  • Phone: 678-556-9460
  • Fax:
Mailing address:
  • Phone: 678-556-9460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MIGUEL E STUBBS
Title or Position: PARTNER
Credential:
Phone: 678-556-9460