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General NPI Number Information
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NPI Number | 1225321508
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Entity Type | Organization
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Legal Business Name | SOUTHERN CROSS SURGERY CENTER, LLC
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Dates
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Enumeration Date | 05/19/2011
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Last Update Date | 04/29/2015
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Provider Practice Location Address
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Address Line | 1301 SIGMAN RD NE SUITE 120
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City | CONYERS
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State | GA
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Zip | 30012-3812
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Country | US
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Telephone | 770-760-9360
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Fax |
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Provider Business Mailing Address
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Address Line | 1301 SIGMAN RD NE SUITE 120
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City | CONYERS
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State | GA
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Zip | 30012-3812
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Country | US
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Telephone | 770-760-9360
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Fax |
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Authorized Official
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Title or Position | MD/OWNER
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Name | DR. R. L. TALLEY JR.
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Credential | MD
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Telephone | 770-760-9360
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 29957
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 029957
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License Number State | GA
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