Healthcare Provider Details

I. General information

NPI: 1437554847
Provider Name (Legal Business Name): SOUTHERN CRESCENT WOMEN'S HEALTH SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 EAGLE SPRIGN DR
STOCKBRIDGE GA
30281
US

IV. Provider business mailing address

115 EAGLE SPRING DR
STOCKBRIDGE GA
30281-6486
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-0064
  • Fax: 770-474-2998
Mailing address:
  • Phone: 770-474-0064
  • Fax: 770-474-2998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number67788
License Number StateGA

VIII. Authorized Official

Name: LYNN STAPLETON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-474-0064