Healthcare Provider Details

I. General information

NPI: 1194975086
Provider Name (Legal Business Name): SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 SILVERWOOD CT SUITE 100
RINCON GA
31326-5131
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 912-826-3927
  • Fax: 912-826-3931
Mailing address:
  • Phone: 912-354-6614
  • Fax: 912-356-9078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173F00000X
TaxonomySleep Specialist (PhD)
License Number036358
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. APRIL YOUNG
Title or Position: ADMINISTRATION
Credential: ADMINISTRATION
Phone: 912-354-6614