Provider Demographics
NPI:1013052182
Name:SOUTHERN CRESCENT NEUROLOGICAL CLINIC,PC
Entity Type:Organization
Organization Name:SOUTHERN CRESCENT NEUROLOGICAL CLINIC,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LAZARUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD ,PHD
Authorized Official - Phone:770-719-2965
Mailing Address - Street 1:1250 HIGHWAY 54 W
Mailing Address - Street 2:102
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4545
Mailing Address - Country:US
Mailing Address - Phone:770-719-2965
Mailing Address - Fax:770-719-2963
Practice Address - Street 1:1250 HIGHWAY 54 W
Practice Address - Street 2:102
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4545
Practice Address - Country:US
Practice Address - Phone:770-719-2965
Practice Address - Fax:770-719-2963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0310582084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000406795DMedicaid
GAGRP2807OtherMEDICARE FACILITY ID
GA=========OtherTIN