Provider Demographics
NPI:1053681155
Name:SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC
Entity Type:Organization
Organization Name:SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC
Other - Org Name:SOUTHEAST LUNG ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-629-0457
Mailing Address - Street 1:340 HODGSON CT
Mailing Address - Street 2:SUITE #2
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-1520
Mailing Address - Country:US
Mailing Address - Phone:912-629-2290
Mailing Address - Fax:912-629-2291
Practice Address - Street 1:11700 MERCY BLVD
Practice Address - Street 2:BLDG #5
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1753
Practice Address - Country:US
Practice Address - Phone:912-927-6270
Practice Address - Fax:912-927-6254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA696088793AMedicaid
GA000272709EMedicaid
GA000148519LMedicaid
GA000788818LMedicaid
GA202I294672Medicare PIN
GA696088793AMedicaid
GA202I114674Medicare PIN
GA11SCHRFMedicare PIN