Basic Information
| Provider Information | |||||||||
| NPI: | 1114449238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFEPLEX MEDICAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LIFEPLEX FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2855 MILLER DR STE 117 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465638091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5749367777 | ||||||||
| FaxNumber: | 5749411072 | ||||||||
| Practice Location | |||||||||
| Address1: | 2855 MILLER DR STE 117 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465638091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5749367777 | ||||||||
| FaxNumber: | 5749411072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2017 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | HOLM | ||||||||
| AuthorizedOfficialFirstName: | BYRON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 5749367777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | IN | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 207Q00000X | 01024911A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.