Healthcare Provider Details

I. General information

NPI: 1366841082
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 121
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: 770-897-7546
  • Fax: 770-991-8521
Mailing address:
  • Phone: 770-897-7056
  • Fax: 770-909-2169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number072683
License Number StateGA

VIII. Authorized Official

Name: JOHN MCCLAIN
Title or Position: CEO
Credential:
Phone: 770-897-7546