Healthcare Provider Details

I. General information

NPI: 1013150101
Provider Name (Legal Business Name): CHILDREN'S HEALTHCARE OF ATLANTA PEDIATRIC NEUROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 04/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5455 MERIDIAN MARKS RD NE SUITE 200
ATLANTA GA
30342-1654
US

IV. Provider business mailing address

1584 TULLIE CIR NE
ATLANTA GA
30329-2311
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5252
  • Fax:
Mailing address:
  • Phone: 404-785-7928
  • Fax: 404-785-7932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MISS TOBY THOMAS
Title or Position: VICE PRESIDENT, MANAGED CARE
Credential:
Phone: 404-785-7924