Provider Demographics
NPI:1225384563
Name:LIFELINE HEALTH AND WELLNESS PHYSICIAN SPECIALTY GROUP
Entity Type:Organization
Organization Name:LIFELINE HEALTH AND WELLNESS PHYSICIAN SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MIRIANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1609-703-6905
Mailing Address - Street 1:1341 N DELAWARE AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-4300
Mailing Address - Country:US
Mailing Address - Phone:215-922-9334
Mailing Address - Fax:215-420-1777
Practice Address - Street 1:1341 N DELAWARE AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-4300
Practice Address - Country:US
Practice Address - Phone:215-922-9334
Practice Address - Fax:215-420-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty