Provider Demographics
NPI:1275830507
Name:SOUTHEAST PULMONARY AND CRITICAL CARE LLC
Entity Type:Organization
Organization Name:SOUTHEAST PULMONARY AND CRITICAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:DENENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-980-5864
Mailing Address - Street 1:370 S HERLONG AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1160
Mailing Address - Country:US
Mailing Address - Phone:803-980-5864
Mailing Address - Fax:803-980-5817
Practice Address - Street 1:370 S HERLONG AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1160
Practice Address - Country:US
Practice Address - Phone:803-980-5864
Practice Address - Fax:803-980-5817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21599261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC215992Medicaid
SCG30809Medicare UPIN
SCG308090281Medicare PIN