Healthcare Provider Details

I. General information

NPI: 1275932998
Provider Name (Legal Business Name): SOUTHERN CRESCENT PHYSICIANS GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 UPPER RIVERDALE RD SW SUITE 112
RIVERDALE GA
30274-2626
US

IV. Provider business mailing address

11 UPPER RIVERDALE RD SW
RIVERDALE GA
30274-2615
US

V. Phone/Fax

Practice location:
  • Phone: 770-897-7056
  • Fax: 770-909-2169
Mailing address:
  • Phone: 770-897-7056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number053450
License Number StateGA

VIII. Authorized Official

Name: JOHN MCCLAIN
Title or Position: CEO
Credential:
Phone: 770-897-7056