Healthcare Provider Details

I. General information

NPI: 1790020444
Provider Name (Legal Business Name): SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 SHERATON BLVD SUITE 2
MACON GA
31210-1359
US

IV. Provider business mailing address

PO BOX 14417
SAVANNAH GA
31416-1417
US

V. Phone/Fax

Practice location:
  • Phone: 912-629-2290
  • Fax: 912-629-2291
Mailing address:
  • Phone: 912-629-2290
  • Fax: 912-629-2291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: APRIL YOUNG
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 912-629-0457