Basic Information
| Provider Information | |||||||||
| NPI: | 1528365111 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 MAIN ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | HILTON HEAD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299266606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436822934 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 MEDICAL CENTER DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HARDEEVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299273447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432083584 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2011 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | ODOM | ||||||||
| AuthorizedOfficialFirstName: | MELANEY | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8436822934 | ||||||||
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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 | 26860 | SC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 26860 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | G44180 | 05 | SC | MEDICAID |