MEDICARE: SOUTHERN CRESCENT PHYSICIANS GROUP, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	016401	GA
2	2084N0400X	Neurology Physician	053450	GA
3	208600000X	Surgery Physician	072683	GA

General Provider Information

NPI Number	:	1174923478
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CRESCENT PHYSICIANS GROUP, INC.

Provider Business Mailing Address
First Line	:	11 UPPER RIVERDALE RD SW
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2615
Country	:	US
Telephone Number	:	770-897-7056
Fax Number	:

Provider Business Practice Location Address
First Line	:	7813 SPIVEY STATION BLVD
Second Line	:	SUITE 100
City	:	JONESBORO
State	:	GA
Zip	:	30236-2900
Country	:	US
Telephone Number	:	770-996-3190
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JOHN MCCLAIN
Credential	:
Telephone Number	:	770-897-7056

Provider Enumeration Date	:	08/25/2014
Last Update Date	:	08/25/2014

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