Provider Demographics
NPI:1639285463
Name:SWABY-ELLIS, EDITH DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:DAWN
Last Name:SWABY-ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 APPLE TREE DR
Mailing Address - Street 2:STONE MOUNTAIN
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-2467
Mailing Address - Country:US
Mailing Address - Phone:404-298-9388
Mailing Address - Fax:
Practice Address - Street 1:3807 CLAIRMONT ROAD
Practice Address - Street 2:NORTH DEKALB GRADY CLINIC
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:404-616-0700
Practice Address - Fax:404-616-3078
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029112208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00331755AMedicaid
GAD30951Medicare UPIN