Provider Demographics
NPI:1508818741
Name:SOUTHERN CRESCENT NURSE ANESTHESIA LLC
Entity Type:Organization
Organization Name:SOUTHERN CRESCENT NURSE ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:770-251-2060
Mailing Address - Street 1:3025 HIGHWAY 154
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-6107
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:
Practice Address - Street 1:5995 SPRING ST
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:31830-2149
Practice Address - Country:US
Practice Address - Phone:770-655-3331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3066Medicare ID - Type Unspecified