Provider Demographics
NPI:1366841082
Name:SOUTHERN CRESCENT PHYSICIANS GROUP, INC.
Entity Type:Organization
Organization Name:SOUTHERN CRESCENT PHYSICIANS GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-897-7546
Mailing Address - Street 1:11 UPPER RIVERDALE RD SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2615
Mailing Address - Country:US
Mailing Address - Phone:770-897-7056
Mailing Address - Fax:770-909-2169
Practice Address - Street 1:33 UPPER RIVERDALE RD SW
Practice Address - Street 2:SUITE 121
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2626
Practice Address - Country:US
Practice Address - Phone:770-897-7546
Practice Address - Fax:770-991-8521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA072683208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP 1598Medicare PIN