Healthcare Provider Details

I. General information

NPI: 1922173723
Provider Name (Legal Business Name): SOUTHERN CRESCENT BREAST SPECIALISTS,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7823 SPIVEY STATION BLVD SUITE 200
LAKE SPIVEY GA
30236-2886
US

IV. Provider business mailing address

7823 SPIVEY STATION BLVD SUITE 200
LAKE SPIVEY GA
30236-2886
US

V. Phone/Fax

Practice location:
  • Phone: 770-507-5055
  • Fax: 770-507-5880
Mailing address:
  • Phone: 770-507-5055
  • Fax: 770-507-5880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. WENDY PEARSON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 770-507-5055