Provider Demographics
NPI:1942353115
Name:SOUTHERN CRESCENT PLASTIC SURGERY ASC
Entity type:Organization
Organization Name:SOUTHERN CRESCENT PLASTIC SURGERY ASC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE 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:2007-01-19
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035432261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00762572AMedicaid
GA111097ASCAMedicare ID - Type UnspecifiedASC ID