Basic Information
| Provider Information | |||||||||
| NPI: | 1245276195 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN CRESCENT ENDOSCOPY SUITE, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048887575 | ||||||||
| FaxNumber: | 4048857777 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 N PARK TRL STE A | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302817372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705070909 | ||||||||
| FaxNumber: | 7709078448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SUH | ||||||||
| AuthorizedOfficialFirstName: | JUNG | ||||||||
| AuthorizedOfficialMiddleName: | WHUN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4048887575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy |
ID Information
| ID | Type | State | Issuer | Description | 00779402A | 05 | GA | MEDICAID |