Basic Information
| Provider Information | |||||||||
| NPI: | 1720285653 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE EMORY CLINIC PEDIATRIC PROVIDERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1365 CLIFTON RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047782144 | ||||||||
| FaxNumber: | 4047784819 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W PONCE DE LEON AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300302528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047782144 | ||||||||
| FaxNumber: | 4047787466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | COOK WALTER | ||||||||
| AuthorizedOfficialFirstName: | DOROTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR SYSTEM CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4047782144 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN, MN, JD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207NP0225X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology | 207XP3100X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207YP0228X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207ZP0213X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology | 2084P0804X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2085P0229X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2086S0120X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
No ID Information.