Provider Demographics
NPI:1437145950
Name:SOUTHERN CRESCENT PEDIATRICS PC
Entity Type:Organization
Organization Name:SOUTHERN CRESCENT PEDIATRICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:SHERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-389-9944
Mailing Address - Street 1:150 MEDICAL BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5053
Mailing Address - Country:US
Mailing Address - Phone:770-389-9944
Mailing Address - Fax:770-389-1973
Practice Address - Street 1:191 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2722
Practice Address - Country:US
Practice Address - Phone:770-389-5500
Practice Address - Fax:770-389-4959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
276714OtherBCBS
7802OtherKAISER POS
0526682OtherAETNA SELECT/US HEALTHC
=========OtherGENERAL
0526682OtherAETNA SELECT/US HEALTHC
276714OtherBCBS