Basic Information
| Provider Information | |||||||||
| NPI: | 1619330164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIFE | ||||||||
| FirstName: | CHAE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1824 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100353832 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 275 CARPENTER DR STE 310 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303284911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8446444325 | ||||||||
| FaxNumber: | 4246250010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2016 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 84099 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.