Healthcare Provider Details

I. General information

NPI: 1730251695
Provider Name (Legal Business Name): CHILDREN'S HEALTHCARE OF ATLANTA AT SCOTTISH RITE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 MERIDIAN MARKS RD NE SUITE 200
ATLANTA GA
30342-4763
US

IV. Provider business mailing address

1584 TULLIE CIR NE
ATLANTA GA
30329-2311
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-3229
  • Fax:
Mailing address:
  • Phone: 404-785-3229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number060-303
License Number StateGA

VIII. Authorized Official

Name: LOUETTA CODY
Title or Position: MANAGER, PROVIDER ENROLLMENT
Credential:
Phone: 404-785-7876