Healthcare Provider Details

I. General information

NPI: 1841281391
Provider Name (Legal Business Name): SOUTHERN CRESCENT ENT, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HOSPITAL DR SUITE 100A
STOCKBRIDGE GA
30281-9075
US

IV. Provider business mailing address

1101 HOSPITAL DR SUITE 100A
STOCKBRIDGE GA
30281-9075
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-7416
  • Fax: 770-389-6210
Mailing address:
  • Phone: 770-474-7416
  • Fax: 770-389-6210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number046956
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number039722
License Number StateGA

VIII. Authorized Official

Name: MELISSA JEAN ELLIOTT
Title or Position: PRACTICIE MANAGER
Credential:
Phone: 770-474-7416