| Southern Crescent Neurological Clinic,pc | |
|
1250 Highway 54 W 102 Fayetteville GA 30214-4545 | |
| (770) 719-2965 | |
| (770) 719-2963 |
| Full Name | Southern Crescent Neurological Clinic,pc |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 1250 Highway 54 W, Fayetteville, Georgia |
| Authorized Official Name and Position | Kenneth Jay Lazarus (CEO) |
| Authorized Official Contact | 7707192965 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Crescent Neurological Clinic,pc 1250 Highway 54 W 102 Fayetteville GA 30214-4545 Ph: (770) 719-2965 | Southern Crescent Neurological Clinic,pc 1250 Highway 54 W 102 Fayetteville GA 30214-4545 Ph: (770) 719-2965 |
| NPI Number | 1013052182 |
|---|---|
| Provider Enumeration Date | 02/20/2007 |
| Last Update Date | 06/21/2018 |
| Medicare PECOS PAC ID | 1254410624 |
|---|---|
| Medicare Enrollment ID | O20080509000549 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1013052182 | NPI | - | NPPES |
| 000406795D | Medicaid | GA | |
| GRP2807 | Other | GA | MEDICARE FACILITY ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084N0400X | Psychiatry & Neurology - Neurology | 031058 (Georgia) | Primary |
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