Basic Information
| Provider Information | |||||||||
| NPI: | 1255475091 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC NEUROSURGERY ASSOC AT CHILDREN'S HEALTHCARE OF ATLANTA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 NORTHEAST EXPY NE STE 540 | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857876 | ||||||||
| FaxNumber: | 4047857932 | ||||||||
| Practice Location | |||||||||
| Address1: | 5455 MERIDIAN MARK RD | ||||||||
| Address2: | SUITE 540 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042556509 | ||||||||
| FaxNumber: | 4042559802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | CODY | ||||||||
| AuthorizedOfficialFirstName: | LOUETTA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER, PAYOR CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 4047857876 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.