Basic Information
| Provider Information | |||||||||
| NPI: | 1265755839 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 EISENHOWER DR STE 1500 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314061603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123546614 | ||||||||
| FaxNumber: | 9123569078 | ||||||||
| Practice Location | |||||||||
| Address1: | 895 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | JESUP | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315450210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125308190 | ||||||||
| FaxNumber: | 9125308191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2010 | ||||||||
| LastUpdateDate: | 03/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | APRIL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9123546614 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | 036358 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000526336A | 05 | GA | MEDICAID |