Basic Information
| Provider Information | |||||||||
| NPI: | 1558727289 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOTHORACIC PROVIDERS AT CHILDRENS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1575 NORTHEAST EXPY NE | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292401 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1575 NORTHEAST EXPY NE | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047855437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2016 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | MATHIESON | ||||||||
| AuthorizedOfficialFirstName: | HAYDEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 4047850589 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.