SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC

Provider Demographics

• NPI: 1598189805
• 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 - First Name: APRIL
• Authorized Official - Last Name: YOUNG
• 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: 122 SCRANTON CONNECTOR
• Practice Address - Street 2: SUITE #112
• Practice Address - City: BRUNSWICK
• Practice Address - State: GA
• Practice Address - Zip Code: 31525-0533
• Practice Address - Country: US
• Practice Address - Phone: 912-629-2290
• Practice Address - Fax: 912-629-2291
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2014-02-06
• Last Update Date: 2014-02-06

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207RP1001X	Allopathic & Osteopathic Physicians	Internal Medicine	Pulmonary Disease	Group - Multi-Specialty
No	363AM0700X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Medical	Group - Multi-Specialty
No	363LA2100X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Acute Care	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
GA	003112189A	Medicaid
GA	003124134C	Medicaid
GA	696088793A	Medicaid
GA	000788818L	Medicaid
GA	003126241A	Medicaid
GA	221012519B	Medicaid
GA	000148519L	Medicaid
GA	003134446A	Medicaid
GA	003137375A	Medicaid
GA	000914922A	Medicaid
GA	487007710A	Medicaid
GA	0004733833F	Medicaid
GA	000526336A	Medicaid
GA	000272709E	Medicaid
GA	003129391A	Medicaid
GA	003129392A	Medicaid
GA	795377228A	Medicaid
GA	50BBFCP	Medicare PIN
GA	202I504201	Medicare PIN
GA	003129392A	Medicaid
GA	0004733833F	Medicaid
GA	11BDWLV	Medicare PIN
GA	202I975803	Medicare PIN
GA	202I294672	Medicare PIN
GA	003137375A	Medicaid
GA	97WCJQB	Medicare PIN
GA	202I114674	Medicare PIN
GA	000148519L	Medicaid
GA	202I819060	Medicare PIN
GA	202I502513	Medicare PIN
GA	795377228A	Medicaid
GA	487007710A	Medicaid
GA	003129391A	Medicaid
GA	29BDBXP	Medicare PIN