Basic Information
| Provider Information | |||||||||
| NPI: | 1457501967 | ||||||||
| 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: | 9123549075 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 GLYNCO PKWY | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | BRUNSWICK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315257921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9122620611 | ||||||||
| FaxNumber: | 9122620881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2008 | ||||||||
| LastUpdateDate: | 02/17/2010 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | APRIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 9123546614 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | ADMINISTRATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173F00000X | 036358 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Sleep Specialist, PhD |
ID Information
| ID | Type | State | Issuer | Description | GRP3039 | 05 | GA | MEDICAID |