1790020444 NPI number — SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC

Table of content: (NPI 1790020444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790020444 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:
1790020444
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2014
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:
912-629-2290
Provider Business Mailing Address Fax Number:
912-629-2291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 SHERATON BLVD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-1359
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:
12/06/2012

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" .
  • Taxonomy code: 207RS0012X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 487007710A , 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".
  • Identifier: 000788818L , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000914922A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000148519L , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 696088793A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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