MEDICARE: EAGAN CONCIERGE MEDICAL GROUP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1083296446
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGAN CONCIERGE MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	2658 GRIFFITH PARK BLVD STE 305
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-2520
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2658 GRIFFITH PARK BLVD STE 305
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-2520
Country	:	US
Telephone Number	:	310-702-9803
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	BREANNA SPLAIN
Credential	:
Telephone Number	:	760-835-6880

Provider Enumeration Date	:	04/26/2021
Last Update Date	:	04/26/2021

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