Healthcare Provider Details

I. General information

NPI: 1184779332
Provider Name (Legal Business Name): SCOTTISH RITE CHILDREN'S MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 JOHNSON FERRY RD NE
ATLANTA GA
30342-1605
US

IV. Provider business mailing address

1575 NORTHEAST EXPY NE
BROOKHAVEN GA
30329-2401
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RUTH FOWLER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 404-785-5437