Provider Demographics
NPI:1831374982
Name:SOUTHERN CRESCENT PAIN MANAGEMENT LLC
Entity type:Organization
Organization Name:SOUTHERN CRESCENT PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUFEMI
Authorized Official - Middle Name:AYOTUNDE
Authorized Official - Last Name:OGUNYEMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-284-1232
Mailing Address - Street 1:147 N PARK TRL
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7373
Mailing Address - Country:US
Mailing Address - Phone:678-284-1232
Mailing Address - Fax:678-284-1296
Practice Address - Street 1:147 N PARK TRL
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7373
Practice Address - Country:US
Practice Address - Phone:678-284-1232
Practice Address - Fax:678-284-1296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045566208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA682664Medicare UPIN