MEDICARE: SOUTHERN CRESCENT PEDIATRICS PC

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	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	276714	OTHER	BCBS
2	7802	OTHER	KAISER POS
3	0526682	OTHER	AETNA SELECT/US HEALTHC

General Provider Information

NPI Number	:	1437145950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CRESCENT PEDIATRICS PC

Provider Business Mailing Address
First Line	:	150 MEDICAL BLVD
Second Line	:	STE B
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-5053
Country	:	US
Telephone Number	:	770-389-9944
Fax Number	:	770-389-1973

Provider Business Practice Location Address
First Line	:	191 FAIRVIEW RD
Second Line	:
City	:	ELLENWOOD
State	:	GA
Zip	:	30294-2722
Country	:	US
Telephone Number	:	770-389-5500
Fax Number	:	770-389-4959

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JUAN JOSE SHERWOOD
Credential	:	MD
Telephone Number	:	770-389-9944

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	08/22/2020

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