Healthcare Provider Details

I. General information

NPI: 1346547833
Provider Name (Legal Business Name): SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MAIN ST SUITE 202
HILTON HEAD SC
29926-6606
US

IV. Provider business mailing address

23 MAIN ST SUITE 202
HILTON HEAD SC
29926-6606
US

V. Phone/Fax

Practice location:
  • Phone: 843-682-2934
  • Fax: 843-682-3597
Mailing address:
  • Phone: 843-682-2934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number19179
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number19179
License Number StateSC

VIII. Authorized Official

Name: MELANEY G ODOM
Title or Position: ADMINISTRATOR
Credential:
Phone: 843-682-2934