Provider Demographics
NPI:1922267129
Name:SOUTHERN CRESCENT PRIMARY CARE
Entity Type:Organization
Organization Name:SOUTHERN CRESCENT PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:OLUBUSOLA
Authorized Official - Last Name:OGUNDIPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHD,CMD
Authorized Official - Phone:678-610-2916
Mailing Address - Street 1:7823 SPIVEY STATION BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2886
Mailing Address - Country:US
Mailing Address - Phone:678-610-2916
Mailing Address - Fax:678-610-2925
Practice Address - Street 1:7823 SPIVEY STATION BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2886
Practice Address - Country:US
Practice Address - Phone:678-610-2916
Practice Address - Fax:678-610-2925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000639768BMedicaid
GA110239410OtherRAILROAD MEDICARE
GA000639768BMedicaid
GAG02934Medicare UPIN