1346547833 NPI number — SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346547833 NPI number — SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346547833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
HILTON HEAD
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29926-6606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-682-2934
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
HILTON HEAD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29926-6606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-682-2934
Provider Business Practice Location Address Fax Number:
843-682-3597
Provider Enumeration Date:
02/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ODOM
Authorized Official First Name:
MELANEY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
843-682-2934

Provider Taxonomy Codes

  • Taxonomy code: 207RS0012X , with the licence number:  19179 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 19179 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: T32088 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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