Provider Demographics
NPI:1225321508
Name:SOUTHERN CROSS SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERN CROSS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:R.
Authorized Official - Middle Name:L
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-760-9360
Mailing Address - Street 1:1301 SIGMAN RD NE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3812
Mailing Address - Country:US
Mailing Address - Phone:770-760-9360
Mailing Address - Fax:
Practice Address - Street 1:1301 SIGMAN RD NE
Practice Address - Street 2:SUITE 120
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3812
Practice Address - Country:US
Practice Address - Phone:770-760-9360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA29957261Q00000X
GA029957261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G490818OtherMEDICARE PTAN