Provider Demographics
NPI:1881764553
Name:CHILDRENS HEALTHCARE OF ATLANTA SURGERY CENTER AT MERIDIAN MARK PLAZA
Entity type:Organization
Organization Name:CHILDRENS HEALTHCARE OF ATLANTA SURGERY CENTER AT MERIDIAN MARK PLAZA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MANAGED
Authorized Official - Middle Name:
Authorized Official - Last Name:CARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-785-5437
Mailing Address - Street 1:1575 NE EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2317
Mailing Address - Country:US
Mailing Address - Phone:404-785-7876
Mailing Address - Fax:
Practice Address - Street 1:5445 MERIDIAN MARKS RD NE
Practice Address - Street 2:SUITE 340
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4763
Practice Address - Country:US
Practice Address - Phone:404-785-5650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-256261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000975972AOtherPEACH STATE PROVIDER ID
GA10052301OtherAMERIGROUP PROVIDER ID
GA322410OtherWELLCARE PROVIDER ID
GA000975972AMedicaid