Provider Demographics
NPI:1205193398
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:PO BOX 14417
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-1417
Mailing Address - Country:US
Mailing Address - Phone:912-629-2290
Mailing Address - Fax:912-629-2291
Practice Address - Street 1:11706 MERCY BLVD
Practice Address - Street 2:BLDG #4
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1751
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:2012-04-13
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA487007710AMedicaid
GA000526336AMedicaid
GA000914922AMedicaid
GA000788818LMedicaid
GA000148519LMedicaid
GA696088793AMedicaid
GA11BDWLVMedicare PIN
GA696088793AMedicaid
GA11SCHRFMedicare PIN
GA000788818LMedicaid
GA29BDCFNMedicare PIN
GA202I114674Medicare PIN