Provider Demographics
NPI:1922402122
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 - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-629-0457
Mailing Address - Street 1:PO BOX 14417
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-1417
Mailing Address - Country:US
Mailing Address - Phone:912-629-2290
Mailing Address - Fax:912-629-2291
Practice Address - Street 1:230 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0102
Practice Address - Country:US
Practice Address - Phone:912-629-2290
Practice Address - Fax:912-629-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-16
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126241AMedicaid
GA003137375AMedicaid
GA221012519BMedicaid
GA003124134CMedicaid
GA003129391AMedicaid
GA795377228AMedicaid
GA000473833FMedicaid
GA000526336AMedicaid
GA003129392AMedicaid
GA003134446AMedicaid
GA795377228AMedicaid
GA221012519BMedicaid
GA50BBFCPMedicare PIN
GA202I500568Medicare PIN
GA29BDBXPMedicare PIN
GA003129391AMedicaid
GA003129392AMedicaid
GA202I975623Medicare PIN
GA97WCJQBMedicare PIN
GA003134446AMedicaid
GA202I975803Medicare PIN