Basic Information
| Provider Information | |||||||||
| NPI: | 1922441054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFE MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14614 LIVINGSTON AVE | ||||||||
| Address2: | |||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335593101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139727979 | ||||||||
| FaxNumber: | 8139722424 | ||||||||
| Practice Location | |||||||||
| Address1: | 14614 LIVINGSTON AVE | ||||||||
| Address2: | |||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335593101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139727979 | ||||||||
| FaxNumber: | 8139722424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2013 | ||||||||
| LastUpdateDate: | 03/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | RIDLEY-PAYNE | ||||||||
| AuthorizedOfficialFirstName: | ADRIANNE | ||||||||
| AuthorizedOfficialMiddleName: | MARIA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8139727979 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ME82833 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 12523258 | 01 | FL | CAQH | OTHER |