Healthcare Provider Details

I. General information

NPI: 1720285653
Provider Name (Legal Business Name): THE EMORY CLINIC PEDIATRIC PROVIDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W PONCE DE LEON AVE STE 300
DECATUR GA
30030-2528
US

IV. Provider business mailing address

1365 CLIFTON RD NE
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-2144
  • Fax: 404-778-7466
Mailing address:
  • Phone: 404-778-2144
  • Fax: 404-778-4819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DOROTHY COOK WALTER
Title or Position: DIRECTOR SYSTEM CREDENTIALING
Credential: RN, MN, JD
Phone: 404-778-2144