=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265995401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAGAN MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2019
-----------------------------------------------------
Last Update Date | 04/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8140 N MOPAC EXPY STE 150
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-8837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-766-5613
-----------------------------------------------------
Fax | 512-535-1413
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8140 N MOPAC EXPY STE 150
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-8837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-665-6138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | BREANNA SPLAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-369-8037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------