Healthcare Provider Details

I. General information

NPI: 1922178789
Provider Name (Legal Business Name): SCOTTISH RITE CHILDRENS MEDICAL CTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
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: 404-785-7876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number060-303
License Number StateGA

VIII. Authorized Official

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