Basic Information
| Provider Information | |||||||||
| NPI: | 1013150101 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HEALTHCARE OF ATLANTA PEDIATRIC NEUROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1584 TULLIE CIR NE | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857928 | ||||||||
| FaxNumber: | 4047857932 | ||||||||
| Practice Location | |||||||||
| Address1: | 5455 MERIDIAN MARKS RD NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047855252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2009 | ||||||||
| LastUpdateDate: | 04/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | TOBY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 4047857924 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0008X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.