=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801979174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CRESCENT PHYSICIANS GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 05/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 UPPER RIVERDALE RD SW
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-991-8500
-----------------------------------------------------
Fax | 770-991-8507
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 UPPER RIVERDALE RD SW
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-991-8500
-----------------------------------------------------
Fax | 770-991-8507
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | JOHN MCLAIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-991-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 031442
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------