NPIMap

Organization Active NPI

Southern Crescent Pediatrics PC

  • Pediatrics Physician
  • Ellenwood, GA
National Provider Identifier
1437145950
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
SOUTHERN CRESCENT PEDIATRICS PC
Practice address
191 Fairview Rd
Ellenwood, GA 30294-2722
Phone
(770) 389-5500
Fax
(770) 389-4959
NPI assigned
Sep 20, 2005
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Juan Jose Sherwood, MDNPI 1417958281
Title
President
Phone
(770) 389-9944

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X Primary

Addresses

Primary practice location

191 Fairview Rd
Ellenwood, GA 30294-2722

Mailing address

150 Medical Blvd
Ste B
Stockbridge, GA 30281-5053
Phone (770) 389-9944

Other identifiers 3

IdentifierTypeStateIssuer
276714OtherBCBS
7802OtherKAISER POS
0526682OtherAETNA SELECT/US HEALTHC

National Provider Directory

National Provider Directory
Tax ID family
Southern Crescent Pediatrics PC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

191 Fairview Rd
Ellenwood, GA 30294
Phone (770) 389-5500

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1127174400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1437145950",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "150 MEDICAL BLVD",
            "address_2": "STE B",
            "city": "STOCKBRIDGE",
            "state": "GA",
            "postal_code": "302815053",
            "telephone_number": "770-389-9944",
            "fax_number": "770-389-1973"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "191 FAIRVIEW RD",
            "city": "ELLENWOOD",
            "state": "GA",
            "postal_code": "302942722",
            "telephone_number": "770-389-5500",
            "fax_number": "770-389-4959"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN CRESCENT PEDIATRICS PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-20",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "SHERWOOD",
        "authorized_official_first_name": "JUAN",
        "authorized_official_middle_name": "JOSE",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "770-389-9944",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "276714",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "KAISER POS",
            "identifier": "7802",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AETNA SELECT/US HEALTHC",
            "identifier": "0526682",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Ellenwood, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.