Provider Demographics
NPI:1114449238
Name:LIFEPLEX MEDICAL INC
Entity Type:Organization
Organization Name:LIFEPLEX MEDICAL INC
Other - Org Name:LIFEPLEX FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-936-7777
Mailing Address - Street 1:2855 MILLER DR STE 117
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-8091
Mailing Address - Country:US
Mailing Address - Phone:574-936-7777
Mailing Address - Fax:574-941-1072
Practice Address - Street 1:2855 MILLER DR STE 117
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8091
Practice Address - Country:US
Practice Address - Phone:574-936-7777
Practice Address - Fax:574-941-1072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024911A207Q00000X
IN261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty