Provider Demographics
NPI:1235114430
Name:SOUTHEASTERN LUNG CARE PC
Entity Type:Organization
Organization Name:SOUTHEASTERN LUNG CARE PC
Other - Org Name:THE SLEEP DISORDERS CENTERS OF SOUTHEASTERN LUNG CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DISCORDIA
Authorized Official - Suffix:
Authorized Official - Credentials:BHA CPC CHCC CMM
Authorized Official - Phone:404-294-4018
Mailing Address - Street 1:1490 MILSTEAD RD NE STE A
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3823
Mailing Address - Country:US
Mailing Address - Phone:770-922-2217
Mailing Address - Fax:770-922-1626
Practice Address - Street 1:1490 MILSTEAD RD NE STE A
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3823
Practice Address - Country:US
Practice Address - Phone:770-922-2217
Practice Address - Fax:770-922-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55001212AMedicaid
GA400116OtherBLUE CROSS BLUE SHIELD
GA55001212AMedicaid