Basic Information
| Provider Information | |||||||||
| NPI: | 1689998536 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 EISENHOWER DR | ||||||||
| Address2: | BUILDING #1500 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314061600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123546614 | ||||||||
| FaxNumber: | 9123569078 | ||||||||
| Practice Location | |||||||||
| Address1: | 209C MIMS RD | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304671994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125645977 | ||||||||
| FaxNumber: | 9125641259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2010 | ||||||||
| LastUpdateDate: | 03/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | MASCOLO | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9123546614 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 052469 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 487007710A | 05 | GA | MEDICAID |