Basic Information
| Provider Information | |||||||||
| NPI: | 1396167557 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SOUTHEAST LUNG ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14417 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314161417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9129276270 | ||||||||
| FaxNumber: | 9129276254 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 E TOLLISON ST | ||||||||
| Address2: | # A | ||||||||
| City: | BAXLEY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315130149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9129276270 | ||||||||
| FaxNumber: | 9129276254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2014 | ||||||||
| LastUpdateDate: | 05/02/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | APRIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9126290457 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 003134446A | 05 | GA | MEDICAID | 003129392A | 05 | GA | MEDICAID | 221012519B | 05 | GA | MEDICAID | 000788818L | 05 | GA | MEDICAID | 003129391A | 05 | GA | MEDICAID | 003124134C | 05 | GA | MEDICAID | 003126241A | 05 | GA | MEDICAID | 003137375A | 05 | GA | MEDICAID | 795377228A | 05 | GA | MEDICAID |