Provider Demographics
NPI:1922178789
Name:SCOTTISH RITE CHILDRENS MEDICAL CTR
Entity Type:Organization
Organization Name:SCOTTISH RITE CHILDRENS MEDICAL CTR
Other - Org Name:CHILDREN'S HEALTHCARE OF ATLANTA AT SCOTTISH RITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR, 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:
Practice Address - Street 1:1001 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1605
Practice Address - Country:US
Practice Address - Phone:404-785-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-303282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000001636AOtherPEACH STATE PROVIDER ID
GA000001636AMedicaid
GA1000062OtherAMERIGROUP PROVIDER ID
GA21316OtherWELLCARE PROVIDER ID
113301Medicare Oscar/Certification
GA1000062OtherAMERIGROUP PROVIDER ID