Provider Demographics
NPI:1780852921
Name:CHILDREN'S CLINIC OF ATLANTA
Entity Type:Organization
Organization Name:CHILDREN'S CLINIC OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NINA
Authorized Official - Middle Name:BRAZELL
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-814-0733
Mailing Address - Street 1:PO BOX 11989
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30355-1989
Mailing Address - Country:US
Mailing Address - Phone:404-814-0733
Mailing Address - Fax:404-814-0584
Practice Address - Street 1:2967 A GRANDVIEW AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305
Practice Address - Country:US
Practice Address - Phone:404-814-0733
Practice Address - Fax:404-814-0584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031559302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization