Provider Demographics
NPI:1841573458
Name:SOUTHERN CRESCENT PLASTIC SURGERY, PC
Entity type:Organization
Organization Name:SOUTHERN CRESCENT PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, CNOR, RNFA
Authorized Official - Phone:770-389-0446
Mailing Address - Street 1:919 EAGLES LANDING PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5011
Mailing Address - Country:US
Mailing Address - Phone:770-389-0446
Mailing Address - Fax:770-389-3530
Practice Address - Street 1:919 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5011
Practice Address - Country:US
Practice Address - Phone:770-389-0446
Practice Address - Fax:770-389-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE02127Medicare UPIN