Basic Information
| Provider Information | |||||||||
| NPI: | 1922173723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN CRESCENT BREAST SPECIALISTS,PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7823 SPIVEY STATION BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKE SPIVEY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302362886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705075055 | ||||||||
| FaxNumber: | 7705075880 | ||||||||
| Practice Location | |||||||||
| Address1: | 7823 SPIVEY STATION BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAKE SPIVEY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302362886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705075055 | ||||||||
| FaxNumber: | 7705075880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | PEARSON | ||||||||
| AuthorizedOfficialFirstName: | WENDY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7705075055 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.