Basic Information
| Provider Information | |||||||||
| NPI: | 1326119405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HEALTHCARE OF ATLANTA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | EMORY UNHIVERSITY COLLEGE OF MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1269 E ROCK SPRINGS RD NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303062266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048767457 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1645 TULLIE CIR NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303292304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047857141 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | WARD | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT PROFESSOR | ||||||||
| AuthorizedOfficialTelephone: | 4048767457 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146D00000X | 45360 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Emergency Medical Service Providers | Personal Emergency Response Attendant |
No ID Information.