Provider Demographics
NPI:1083786941
Name:CHILDREN'S HEALTHCARE OF ATLANTA AT EGLESTON
Entity Type:Organization
Organization Name:CHILDREN'S HEALTHCARE OF ATLANTA AT EGLESTON
Other - Org Name:CHILDREN'S RESPONSE
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MANAGED
Authorized Official - Middle Name:
Authorized Official - Last Name:CARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-785-7876
Mailing Address - Street 1:1575 NORTHEAST EXPY NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2401
Mailing Address - Country:US
Mailing Address - Phone:404-785-7876
Mailing Address - Fax:
Practice Address - Street 1:1405 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1060
Practice Address - Country:US
Practice Address - Phone:404-785-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044-0793416A0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416A0800XTransportation ServicesAmbulanceAir Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000715591BMedicaid
GA10054195OtherAMERIGROUP PROVIDER ID
GA325894OtherWELLCARE PROVIDER ID
GA000715591BMedicaid