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General NPI Number Information
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NPI Number | 1942353115
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Entity Type | Organization
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Legal Business Name | SOUTHERN CRESCENT PLASTIC SURGERY ASC
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Dates
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Enumeration Date | 01/19/2007
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Last Update Date | 02/17/2012
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Provider Practice Location Address
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Address Line | 919 EAGLES LANDING PKWY
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-5011
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Country | US
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Telephone | 770-389-0446
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Fax | 770-389-3530
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Provider Business Mailing Address
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Address Line | 919 EAGLES LANDING PKWY
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-5011
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Country | US
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Telephone | 770-389-0446
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Fax | 770-389-3530
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | ALICE GROSS
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Credential | NURSE RNFA
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Telephone | 770-389-0446
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 035432
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License Number State | GA
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