=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396852570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAGLE PHYSICIANS AND ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 09/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 N CHURCH ST SUITE 2
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27401-1439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-268-3880
-----------------------------------------------------
Fax | 336-268-3881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 14883
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27415-4883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-268-3880
-----------------------------------------------------
Fax | 336-268-3881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, EAGLE BUSINESS SERVICES
-----------------------------------------------------
Name | TERRI S. JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-268-3201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | AS0075
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------