1598781635 NPI number — ATLANTA MEDICAL CENTER, INC.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598781635 NPI number — ATLANTA MEDICAL CENTER, INC.

Employer Identification Number (EIN):

Provider Organization Name:

ATLANTA MEDICAL CENTER, INC.

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

ATLANTA MEDICAL CENTER- SOUTH CAMPUS

Provider Other Organization Name Type Code:

3

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1598781635

Entity Type Code:

Organization

Replacement NPI:

Last Update Date:

03/24/2022

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 741252

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ATLANTA

Provider Business Mailing Address State Name:

GA

Provider Business Mailing Address Postal Code:

30374-1252

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

678-242-2002

Provider Business Mailing Address Fax Number:

678-242-2202

Provider First Line Business Practice Location Address:

1170 CLEVELAND AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

EAST POINT

Provider Business Practice Location Address State Name:

GA

Provider Business Practice Location Address Postal Code:

30344-3615

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

404-466-1170

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

07/14/2006

Authorized Official Last Name:

MOORE

Authorized Official First Name:

WILLIAM

Authorized Official Middle Name:

T.

Authorized Official Title or Position:

CEO

Authorized Official Telephone Number:

404-256-4000

• Taxonomy code: 282N00000X , with the licence number:  060-598 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 1708445 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
• Identifier: 181713800 . This is a "VISTA HEALTH PLAN HMO/POS" identifier . This identifiers is of the category "OTHER".
• Identifier: 979062670 . This is a "AETNA US HEALTHCARE (NATI" identifier . This identifiers is of the category "OTHER".
• Identifier: 100054 . This is a "BCBS OF GEORGIA" identifier . This identifiers is of the category "OTHER".
• Identifier: 300042914A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
• Identifier: 00382509 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
• Identifier: 08500709 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
• Identifier: 109906 . This is a "COVENTRY HEALTH CARE GEOR" identifier . This identifiers is of the category "OTHER".
• Identifier: 75-2918809 . This is a "TENET EMPLOYEES BENEFIT P" identifier . This identifiers is of the category "OTHER".
• Identifier: 0542792 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 110219B000000 . This is a "SECTION 1011" identifier . This identifiers is of the category "OTHER".