Provider Demographics
NPI:1841281391
Name:SOUTHERN CRESCENT ENT, P.C.
Entity type:Organization
Organization Name:SOUTHERN CRESCENT ENT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICIE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-474-7416
Mailing Address - Street 1:1101 HOSPITAL DR
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9075
Mailing Address - Country:US
Mailing Address - Phone:770-474-7416
Mailing Address - Fax:770-389-6210
Practice Address - Street 1:1101 HOSPITAL DR
Practice Address - Street 2:SUITE 100A
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9075
Practice Address - Country:US
Practice Address - Phone:770-474-7416
Practice Address - Fax:770-389-6210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046956207YX0901X
GA039722207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & NeurotologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00677553AMedicaid
GA04BDBZD01Medicare ID - Type UnspecifiedBLANCA DURAND
GAD40713Medicare UPIN
GA00677553AMedicaid
GAF99654Medicare UPIN
GA04BDCHSMedicare ID - Type UnspecifiedMICHAEL AVIDANO