Healthcare Provider Details

I. General information

NPI: 1225321508
Provider Name (Legal Business Name): SOUTHERN CROSS SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SIGMAN RD NE SUITE 120
CONYERS GA
30012-3812
US

IV. Provider business mailing address

1301 SIGMAN RD NE SUITE 120
CONYERS GA
30012-3812
US

V. Phone/Fax

Practice location:
  • Phone: 770-760-9360
  • Fax:
Mailing address:
  • Phone: 770-760-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number29957
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number029957
License Number StateGA

VIII. Authorized Official

Name: DR. R. L. TALLEY JR.
Title or Position: MD/OWNER
Credential: MD
Phone: 770-760-9360