Healthcare Provider Details

I. General information

NPI: 1376793265
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: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

340 EISENHOWER DR. BLDG. 1500
SAVANNAH GA
31406
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 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:

# 1
Identifier29BDBXP
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: APRIL YOUNG
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 912-629-2290