Provider Demographics
NPI:1689998536
Name:SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS
Entity Type:Organization
Organization Name:SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASCOLO
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:912-354-6614
Mailing Address - Street 1:340 EISENHOWER DR
Mailing Address - Street 2:BUILDING #1500
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-1600
Mailing Address - Country:US
Mailing Address - Phone:912-354-6614
Mailing Address - Fax:912-356-9078
Practice Address - Street 1:209C MIMS RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467-1994
Practice Address - Country:US
Practice Address - Phone:912-564-5977
Practice Address - Fax:912-564-1259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052469207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA487007710AMedicaid
GAG69315Medicare UPIN