Provider Demographics
NPI:1922173723
Name:SOUTHERN CRESCENT BREAST SPECIALISTS,PC
Entity Type:Organization
Organization Name:SOUTHERN CRESCENT BREAST SPECIALISTS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-507-5055
Mailing Address - Street 1:7823 SPIVEY STATION BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKE SPIVEY
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2886
Mailing Address - Country:US
Mailing Address - Phone:770-507-5055
Mailing Address - Fax:770-507-5880
Practice Address - Street 1:7823 SPIVEY STATION BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKE SPIVEY
Practice Address - State:GA
Practice Address - Zip Code:30236-2886
Practice Address - Country:US
Practice Address - Phone:770-507-5055
Practice Address - Fax:770-507-5880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty