Provider Demographics
NPI:1528365111
Name:SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC
Entity Type:Organization
Organization Name:SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-682-2934
Mailing Address - Street 1:23 MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HILTON HEAD
Mailing Address - State:SC
Mailing Address - Zip Code:29926-6606
Mailing Address - Country:US
Mailing Address - Phone:843-682-2934
Mailing Address - Fax:
Practice Address - Street 1:1010 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:HARDEEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29927-3447
Practice Address - Country:US
Practice Address - Phone:843-208-3584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26860207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG44180Medicaid
SCG904146167Medicare PIN
SCG09414Medicare UPIN