Basic Information
Provider Information | |||||||||
NPI: | 1194153874 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHEAST LUNG ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 14417 | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314161417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9126292290 | ||||||||
FaxNumber: | 9126292291 | ||||||||
Practice Location | |||||||||
Address1: | 11800 ABERCORN ST | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314191908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9129276270 | ||||||||
FaxNumber: | 9129276254 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2013 | ||||||||
LastUpdateDate: | 04/30/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | APRIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 9126290457 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 300033643M | 05 | GA |   | MEDICAID | 696088793A | 05 | GA |   | MEDICAID |