MEDICARE: SOUTHERN CRESCENT BREAST SPECIALISTS,PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1922173723
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CRESCENT BREAST SPECIALISTS,PC

Provider Business Mailing Address
First Line	:	7823 SPIVEY STATION BLVD
Second Line	:	SUITE 200
City	:	LAKE SPIVEY
State	:	GA
Zip	:	30236-2886
Country	:	US
Telephone Number	:	770-507-5055
Fax Number	:	770-507-5880

Provider Business Practice Location Address
First Line	:	7823 SPIVEY STATION BLVD
Second Line	:	SUITE 200
City	:	LAKE SPIVEY
State	:	GA
Zip	:	30236-2886
Country	:	US
Telephone Number	:	770-507-5055
Fax Number	:	770-507-5880

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. WENDY PEARSON
Credential	:
Telephone Number	:	770-507-5055

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	08/08/2008

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