1013052182 NPI number — SOUTHERN CRESCENT NEUROLOGICAL CLINIC,PC

Table of content: (NPI 1013052182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013052182 NPI number — SOUTHERN CRESCENT NEUROLOGICAL CLINIC,PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CRESCENT NEUROLOGICAL CLINIC,PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013052182
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1250 HIGHWAY 54 W
Provider Second Line Business Mailing Address:
102
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-4545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-719-2965
Provider Business Mailing Address Fax Number:
770-719-2963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 HIGHWAY 54 W
Provider Second Line Business Practice Location Address:
102
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-4545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-719-2965
Provider Business Practice Location Address Fax Number:
770-719-2963
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LAZARUS
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
770-719-2965

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  031058 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000406795D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GRP2807 . This is a "MEDICARE FACILITY ID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com