Basic Information
| Provider Information | |||||||||
| NPI: | 1730251695 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HEALTHCARE OF ATLANTA AT SCOTTISH RITE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1584 TULLIE CIR NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047853229 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5445 MERIDIAN MARKS RD NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303424763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047853229 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | MATHIESON | ||||||||
| AuthorizedOfficialFirstName: | HAYDEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 4047850589 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 060-303 | GA | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 000001636D | 05 | GA | MEDICAID | 10060840 | 01 | GA | AMERIGROUP PROVIDER ID | OTHER | 000001636D | 01 | GA | PEACH STATE PROVIDER ID | OTHER | 325813 | 01 | GA | WELLCARE PROVIDER ID | OTHER |