Basic Information
| Provider Information | |||||||||
| NPI: | 1518339209 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORELIFE HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 BENFIELD BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211083005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436794309 | ||||||||
| FaxNumber: | 8557724748 | ||||||||
| Practice Location | |||||||||
| Address1: | 579 BALTIMORE ANNAPOLIS BLVD | ||||||||
| Address2: | |||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211463809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109755447 | ||||||||
| FaxNumber: | 8887098865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2015 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | IZZI | ||||||||
| AuthorizedOfficialFirstName: | STEPHAN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4109755447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0025782 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.