Basic Information
| Provider Information | |||||||||
| NPI: | 1629342845 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHEAST LUNG ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14417 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314161417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126292290 | ||||||||
| FaxNumber: | 9126292291 | ||||||||
| Practice Location | |||||||||
| Address1: | 5353 REYNOLDS ST | ||||||||
| Address2: | 4 SOUTH | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126292290 | ||||||||
| FaxNumber: | 9126292291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2012 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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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 | 000914922A | 05 | GA | MEDICAID | 696088793A | 05 | GA | MEDICAID | 000526336A | 05 | GA | MEDICAID | 000788818L | 05 | GA | MEDICAID | 003112189A | 05 | GA | MEDICAID | 487007710A | 05 | GA | MEDICAID | 000148519L | 05 | GA | MEDICAID | 000272709E | 05 | GA | MEDICAID | 000473833F | 05 | GA | MEDICAID |