Provider Demographics
NPI:1457695488
Name:CHOA HOSPITAL BASED, LLC
Entity type:Organization
Organization Name:CHOA HOSPITAL BASED, LLC
Other - Org Name:
Other - Org Type:
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 NE EXPRESSWAY
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 1:1405 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1060
Practice Address - Country:US
Practice Address - Phone:404-785-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Multi-Specialty
No207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric PathologyGroup - Multi-Specialty
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Multi-Specialty
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty