Healthcare Provider Details

I. General information

NPI: 1053640367
Provider Name (Legal Business Name): SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2009
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 E TOLLISON ST
BAXLEY GA
31513-0120
US

IV. Provider business mailing address

340 EISENHOWER DR BLDG. 1500
SAVANNAH GA
31406-1600
US

V. Phone/Fax

Practice location:
  • Phone: 912-354-6614
  • Fax: 912-356-9078
Mailing address:
  • Phone: 912-354-6614
  • Fax: 912-356-9078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173F00000X
TaxonomySleep Specialist (PhD)
License Number032635
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number032635
License Number StateGA

VIII. Authorized Official

Name: APRIL YOUNG
Title or Position: PRACTICE MANAGER
Credential:
Phone: 912-354-6614