Healthcare Provider Details

I. General information

NPI: 1316456825
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: 09/27/2017
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 BIG SHANTY ROAD, NW STE 100
KENNESAW GA
30144-3646
US

IV. Provider business mailing address

1575 NE EXPRESSWAY
ATLANTA GA
30329-2401
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-3229
  • Fax: 404-785-5690
Mailing address:
  • Phone: 404-785-7876
  • Fax: 404-785-7932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

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