Provider Demographics
NPI:1093716979
Name:DEKALB MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:DEKALB MEDICAL CENTER, INC.
Other - Org Name:EMORY DECATUR HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:AVA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAUNT-SAMFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-501-5025
Mailing Address - Street 1:2701 N DECATUR RD STE 1003B
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5918
Mailing Address - Country:US
Mailing Address - Phone:404-501-5025
Mailing Address - Fax:404-501-5627
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:404-501-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044039282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000000536AMedicaid
GA100047OtherBCBS PROVIDER NUMBER
GA100047OtherBCBS PROVIDER NUMBER