Basic Information
| Provider Information | |||||||||
| NPI: | 1316456825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HEALTHCARE OF ATLANTA AT SCOTTISH RITE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ORTHOTICS AND PROSTHETICS AT TOWN CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 NORTHEAST EXPY NE | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857876 | ||||||||
| FaxNumber: | 4047857932 | ||||||||
| Practice Location | |||||||||
| Address1: | 605 BIG SHANTY ROAD, NW | ||||||||
| Address2: | STE 100 | ||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301443646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047853229 | ||||||||
| FaxNumber: | 4047855690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2017 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | MATHIESOIN | ||||||||
| AuthorizedOfficialFirstName: | HAYDEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 4047850589 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
No ID Information.