Organization
SOUTHERN CRESCENT NEUROLOGICAL CLINIC,PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KENNETH JAY LAZARUS M.D. ,P.H.D. (CEO)
(770) 719-2965
Entity
Organization
Contact information
Practice address
1250 HIGHWAY 54 W, 102, FAYETTEVILLE, GA 30214-4545
(770) 719-2965
(770) 719-2963
Mailing address
1250 HIGHWAY 54 W, 102, FAYETTEVILLE, GA 30214-4545
(770) 719-2965
(770) 719-2963
Taxonomy
Speciality
Code
Description
License number
State
2084N0400X
Neurology Physician
Primary
031058
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000406795D
—
GA
01
—
GRP2807
MEDICARE FACILITY ID
GA
Enumeration date
02/20/2007
Last updated
06/21/2018
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