1770857468 NPI number — SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS,P.C.

Table of content: (NPI 1770857468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770857468 NPI number — SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS,P.C.
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:
1770857468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 HODGSON CT
Provider Second Line Business Mailing Address:
SUITE #2
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31406-1520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-629-2290
Provider Business Mailing Address Fax Number:
912-629-2291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COLONIAL WAY
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
JESUP
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31545-0130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-629-2290
Provider Business Practice Location Address Fax Number:
912-629-2291
Provider Enumeration Date:
02/28/2012

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: 000473833F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000526336A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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