Basic Information
Provider Information | |||||||||
NPI: | 1164711818 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 340 EISENHOWER DR | ||||||||
Address2: | BLDG 1500 | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314061600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123546614 | ||||||||
FaxNumber: | 9123569078 | ||||||||
Practice Location | |||||||||
Address1: | 515 E WINTHROPE AVE | ||||||||
Address2: |   | ||||||||
City: | MILLEN | ||||||||
State: | GA | ||||||||
PostalCode: | 304421818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9123546614 | ||||||||
FaxNumber: | 9123569078 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2011 | ||||||||
LastUpdateDate: | 04/04/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DALY | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9123546614 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 36358 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | 36358 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
ID | Type | State | Issuer | Description | CI7230 | 01 | GA | RAILROAD MEDICARE | OTHER | CI9902 | 01 | GA | RAILROAD MEDICARE | OTHER |