Basic Information
| Provider Information | |||||||||
| NPI: | 1215444252 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EGLESTON CHILDREN'S HOSPITAL AT EMORY UNIVERSITY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1587 NORTHEAST EXPRESSWAY | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857928 | ||||||||
| FaxNumber: | 4047857932 | ||||||||
| Practice Location | |||||||||
| Address1: | 1405 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047855252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2017 | ||||||||
| LastUpdateDate: | 12/29/2017 | ||||||||
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| AuthorizedOfficialLastName: | HUFFMAN | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | TRENT | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER, PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4047857928 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EGLESTON CHILDREN'S HOSPITAL AT EMORY UNIVERSITY, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | PHRE005903 | GA | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336I0012X | PHRE005903 | GA | N | Suppliers | Pharmacy | Institutional Pharmacy | 333600000X | PHRE005903 | GA | Y | Suppliers | Pharmacy |
No ID Information.