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General NPI Number Information
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NPI Number | 1043440530
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICAL AND URGENT CARE CLINIC OF MCDONOUGH, LLC
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Dates
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Enumeration Date | 07/20/2009
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Last Update Date | 01/12/2026
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Provider Practice Location Address
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Address Line | 1631 HWY 20 W
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City | MCDONOUGH
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State | GA
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Zip | 30253-7311
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Country | US
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Telephone | 770-288-2822
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Fax | 770-288-2820
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Provider Business Mailing Address
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Address Line | 1631 HWY 20 W
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City | MCDONOUGH
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State | GA
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Zip | 30253-7311
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Country | US
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Telephone | 770-288-2822
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Fax | 770-288-2820
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Authorized Official
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Title or Position | ADMINISTRATIVE OPERATIONS MANAGER
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Name | DANIELLE O EIDSON
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Credential |
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Telephone | 770-288-2822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 004088
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 056874
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License Number State | GA
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