Healthcare Provider Details

I. General information

NPI: 1790909885
Provider Name (Legal Business Name): MYLENE COLUCCI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5354 REYNOLDS ST STE 424
SAVANNAH GA
31405-6011
US

IV. Provider business mailing address

5354 REYNOLDS ST STE 424
SAVANNAH GA
31405-6011
US

V. Phone/Fax

Practice location:
  • Phone: 912-819-5999
  • Fax: 912-819-5980
Mailing address:
  • Phone: 912-819-5999
  • Fax: 912-819-5980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number102233
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberME162038
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number226904
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME162038
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: