Basic Information
| Provider Information | |||||||||
| NPI: | 1811463086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW LIFE MEDICAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3025 NASSAU DR | ||||||||
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| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530453454 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 OPITZ BLVD | ||||||||
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| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221913311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035231000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2018 | ||||||||
| LastUpdateDate: | 10/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | BIRU | ||||||||
| AuthorizedOfficialFirstName: | NEBIYU | ||||||||
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| AuthorizedOfficialTitleorPosition: | CRITICAL CARE MEDICINE | ||||||||
| AuthorizedOfficialTelephone: | 7329397248 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No ID Information.