Basic Information
| Provider Information | |||||||||
| NPI: | 1043521859 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEST LUNG & CRITICAL CARE SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 EISENHOWER DR | ||||||||
| Address2: | BUILDING 1500 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314061600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123546614 | ||||||||
| FaxNumber: | 9123569078 | ||||||||
| Practice Location | |||||||||
| Address1: | 1821B OLD OCILLA ROAD | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123546614 | ||||||||
| FaxNumber: | 9123569078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2010 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | DALY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9123546614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173F00000X | 036358 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Sleep Specialist, PhD |
ID Information
| ID | Type | State | Issuer | Description | CI9902 | 01 | SC | RAILROAD MEDICARE | OTHER | CI7230 | 01 | GA | RAILROAD MEDICARE | OTHER |