Basic Information
| Provider Information | |||||||||
| NPI: | 1598781635 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTA MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ATLANTA MEDICAL CENTER- SOUTH CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 741252 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303741252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782422002 | ||||||||
| FaxNumber: | 6782422202 | ||||||||
| Practice Location | |||||||||
| Address1: | 1170 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | EAST POINT | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303443615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4044661170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4042564000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | N | Transportation Services | Ambulance | 282N00000X | 060-598 | GA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1708445 | 05 | LA | MEDICAID | 181713800 | 01 | VISTA HEALTH PLAN HMO/POS | OTHER | 979062670 | 01 | AETNA US HEALTHCARE (NATI | OTHER | 100054 | 01 | BCBS OF GEORGIA | OTHER | 300042914A | 05 | GA | MEDICAID | 00382509 | 05 | NY | MEDICAID | 08500709 | 05 | MS | MEDICAID | 109906 | 01 | COVENTRY HEALTH CARE GEOR | OTHER | 75-2918809 | 01 | TENET EMPLOYEES BENEFIT P | OTHER | 0542792 | 05 | OH | MEDICAID | 110219B000000 | 01 | SECTION 1011 | OTHER |