1396167557 NPI number — SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC

Table of content: (NPI 1396167557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396167557 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:
6
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:
1396167557
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14417
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31416-1417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-927-6270
Provider Business Mailing Address Fax Number:
912-927-6254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 E TOLLISON ST
Provider Second Line Business Practice Location Address:
# A
Provider Business Practice Location Address City Name:
BAXLEY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31513-0149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-927-6270
Provider Business Practice Location Address Fax Number:
912-927-6254
Provider Enumeration Date:
01/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
APRIL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
912-629-0457

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003134446A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003129392A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 221012519B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000788818L , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003129391A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003124134C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003126241A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003137375A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 795377228A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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