Provider Demographics
NPI:1619290277
Name:SCOTTISH RITE CHILDREN'S MEDICAL CENTER
Entity Type:Organization
Organization Name:SCOTTISH RITE CHILDREN'S MEDICAL CENTER
Other - Org Name:CHILDREN'S HEALTHCARE OF ATLANTA AT SCOTTISH RITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:LOUETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CODY
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:404-785-7932
Practice Address - Street 1:175 WHITE ST NW
Practice Address - Street 2:SUITE 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1053
Practice Address - Country:US
Practice Address - Phone:404-785-8250
Practice Address - Fax:404-785-8251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HEALTHCARE OF ATLANTA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-10
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
No335E00000XSuppliersProsthetic/Orthotic Supplier