Healthcare Provider Details

I. General information

NPI: 1639285463
Provider Name (Legal Business Name): EDITH DAWN SWABY-ELLIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3807 CLAIRMONT ROAD NORTH DEKALB GRADY CLINIC
CHAMBLEE GA
30341
US

IV. Provider business mailing address

4370 APPLE TREE DR STONE MOUNTAIN
STONE MOUNTAIN GA
30083-2467
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-0700
  • Fax: 404-616-3078
Mailing address:
  • Phone: 404-298-9388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number029112
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00331755A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: