Basic Information
Provider Information | |||||||||
NPI: | 1801021464 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIFELINC ANESTHESIA, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3340 PLAYERS CLUB PKWY | ||||||||
Address2: | SUITE 350 | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381258933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9012072017 | ||||||||
FaxNumber: | 8447522163 | ||||||||
Practice Location | |||||||||
Address1: | 3340 PLAYERS CLUB PKWY STE 350 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381258949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9012072017 | ||||||||
FaxNumber: | 8447522163 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2009 | ||||||||
LastUpdateDate: | 09/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WARREN | ||||||||
AuthorizedOfficialFirstName: | ERICA | ||||||||
AuthorizedOfficialMiddleName: | N | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 9012072017 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MHA | ||||||||
NPICertificationDate: | 09/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 207L00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 1029018500001 | 05 | PA |   | MEDICAID | 7100313110 | 05 | KY |   | MEDICAID | 002565700 | 05 | FL |   | MEDICAID | 01886811 | 05 | MS |   | MEDICAID | GPB038 | 05 | SC |   | MEDICAID | 003116254A | 05 | GA |   | MEDICAID | 005473200 | 05 | FL |   | MEDICAID | 005473201 | 05 | FL |   | MEDICAID | 179927002 | 05 | AR |   | MEDICAID | 1514226 | 05 | TN |   | MEDICAID | 005473202 | 05 | FL |   | MEDICAID | 005473203 | 05 | FL |   | MEDICAID |