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General NPI Number Information
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NPI Number | 1013052182
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Entity Type | Organization
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Legal Business Name | SOUTHERN CRESCENT NEUROLOGICAL CLINIC,PC
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 1250 HIGHWAY 54 W 102
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4545
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Country | US
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Telephone | 770-719-2965
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Fax | 770-719-2963
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Provider Business Mailing Address
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Address Line | 1250 HIGHWAY 54 W 102
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-4545
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Country | US
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Telephone | 770-719-2965
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Fax | 770-719-2963
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Authorized Official
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Title or Position | CEO
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Name | DR. KENNETH JAY LAZARUS
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Credential | M.D. ,P.H.D.
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Telephone | 770-719-2965
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 031058
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License Number State | GA
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