Basic Information
Provider Information | |||||||||
NPI: | 1619290277 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SCOTTISH RITE CHILDREN'S MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHILDREN'S HEALTHCARE OF ATLANTA AT SCOTTISH RITE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1575 NORTHEAST EXPY NE | ||||||||
Address2: |   | ||||||||
City: | BROOKHAVEN | ||||||||
State: | GA | ||||||||
PostalCode: | 303292401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047857876 | ||||||||
FaxNumber: | 4047857932 | ||||||||
Practice Location | |||||||||
Address1: | 175 WHITE ST NW | ||||||||
Address2: | SUITE 350 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047858250 | ||||||||
FaxNumber: | 4047858251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/10/2010 | ||||||||
LastUpdateDate: | 10/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MATHIESON | ||||||||
AuthorizedOfficialFirstName: | HAYDEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, MANAGED CARE | ||||||||
AuthorizedOfficialTelephone: | 4047850589 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CHILDREN'S HEALTHCARE OF ATLANTA | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X |   |   | N |   | Suppliers | Prosthetic/Orthotic Supplier |   | 273Y00000X |   |   | Y |   | Hospital Units | Rehabilitation Unit |   |
No ID Information.