1881764553 NPI number — CHILDRENS HEALTHCARE OF ATLANTA SURGERY CENTER AT MERIDIAN MARK PLAZA

Table of content: (NPI 1881764553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881764553 NPI number — CHILDRENS HEALTHCARE OF ATLANTA SURGERY CENTER AT MERIDIAN MARK PLAZA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDRENS HEALTHCARE OF ATLANTA SURGERY CENTER AT MERIDIAN MARK PLAZA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881764553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1575 NORTHEAST EXPY NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKHAVEN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30329-2317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-785-7876
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5445 MERIDIAN MARKS RD NE
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-4763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-785-5650
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CODY
Authorized Official First Name:
LOUETTA
Authorized Official Middle Name:
Authorized Official Title or Position:
MGR, PROVIDER ENROLLMENT
Authorized Official Telephone Number:
404-785-5437

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  060-256 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000975972A . This is a "PEACH STATE PROVIDER ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10052301 . This is a "AMERIGROUP PROVIDER ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 322410 . This is a "WELLCARE PROVIDER ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000975972A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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