Provider Demographics
NPI:1821296088
Name:SOUTHCREST CLINIC, P. C.
Entity Type:Organization
Organization Name:SOUTHCREST CLINIC, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAY
Authorized Official - Middle Name:
Authorized Official - Last Name:SON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:615-333-8383
Mailing Address - Street 1:3413 NOLENSVILLE PIKE
Mailing Address - Street 2:SUITE A
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-2911
Mailing Address - Country:US
Mailing Address - Phone:615-333-8383
Mailing Address - Fax:615-333-1660
Practice Address - Street 1:3413 NOLENSVILLE PIKE
Practice Address - Street 2:SUITE A
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-2911
Practice Address - Country:US
Practice Address - Phone:615-333-8383
Practice Address - Fax:615-333-1660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38730207QA0000X
TNMD42852207QA0000X, 207QA0401X, 207QA0505X
TNMD 38730207QA0505X
TNMD 11290207R00000X, 207RA0401X
TNMD11290208VP0014X
TN6193390001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6193390001Medicare NSC
TN3730247Medicare PIN