Provider Demographics
NPI:1972595999
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 1:150 MEDICAL BLVD
Practice Address - Street 2:STE B
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5053
Practice Address - Country:US
Practice Address - Phone:770-389-9944
Practice Address - Fax:770-389-1973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
265152691OtherCHAMPUS
265152691OtherCHAMPUS
=========OtherHMO/CIGNA