Basic Information
| Provider Information | |||||||||
| NPI: | 1558415232 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EGLESTON PEDATRIC GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1584 TULLIE CIR NE | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857928 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2620 SATELLITE BLVD | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300961204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047858000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUFFMAN | ||||||||
| AuthorizedOfficialFirstName: | TRENT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER, PAYOR CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 4047857928 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.