Providence Healthcare

Primary specialty

Clinical & Laboratory Immunology (Allergy & Immunology) PhysicianTaxonomy code 207KI0005X

Legal business name

PROVIDENCE HEALTHCARE

Practice address

4646 N Shallowford Rd
Atlanta, GA 30338-6304

Phone

(770) 676-6000

Fax

(770) 392-9805

NPI assigned

Mar 30, 2007

Last updated

Jul 21, 2022By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Mary Leach

Title

Office Manager

Phone

(770) 676-6000

Specialties & licenses 3

Addresses

Other identifiers 3

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175212800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1699895961",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4646 N SHALLOWFORD RD",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303386304",
            "telephone_number": "770-676-6000",
            "fax_number": "770-392-9805"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4646 N SHALLOWFORD RD",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303386304",
            "telephone_number": "770-676-6000",
            "fax_number": "770-392-9805"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENCE HEALTHCARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-30",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "LEACH",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "770-676-6000",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "GA",
            "license": "CHIR005530",
            "primary": false
        },
        {
            "code": "171100000X",
            "taxonomy_group": "",
            "desc": "Acupuncturist",
            "state": "FL",
            "license": "000186",
            "primary": false
        },
        {
            "code": "207KI0005X",
            "taxonomy_group": "",
            "desc": "Allergy & Immunology, Clinical & Laboratory Immunology",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUECROSS BLUE SHIELD",
            "identifier": "826713",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TAT",
            "identifier": "50014615",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UPIN",
            "identifier": "D44849",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Proud Smiles LLC
• Casey Prout, MSW
• Matthew Ernest Prout, MD
• Providence Foot & Ankle Centers, P.C. Inc.
• Providence Foot & Ankle Centers, PC Inc
• Providence Healthcare Services, Inc (Boston Healthcare Alliance)
• Providence Home Care LLC
• Providence Medical Group, PC
• Providence Transportation LLC
• Cathleen Ann Provins, RN, ACNP-BC, PHD

• Allergy & Immunology Physician in Atlanta, GA
• Providers in Atlanta, GA by specialty
• Allergy & Immunology Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.