Basic Information
| Provider Information | |||||||||
| NPI: | 1053640367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 EISENHOWER DR | ||||||||
| Address2: | BLDG. 1500 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314061600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123546614 | ||||||||
| FaxNumber: | 9123569078 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 E TOLLISON ST | ||||||||
| Address2: | |||||||||
| City: | BAXLEY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315130120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123546614 | ||||||||
| FaxNumber: | 9123569078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2009 | ||||||||
| LastUpdateDate: | 12/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | APRIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9123546614 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173F00000X | 032635 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Sleep Specialist, PhD | 207RP1001X | 032635 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.