Provider Demographics
NPI:1366823932
Name:LIFESTYLE MEDICINE, INC.
Entity Type:Organization
Organization Name:LIFESTYLE MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-488-9874
Mailing Address - Street 1:2405 E SKELLY DR
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6006
Mailing Address - Country:US
Mailing Address - Phone:918-488-9874
Mailing Address - Fax:918-587-3437
Practice Address - Street 1:2405 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-6006
Practice Address - Country:US
Practice Address - Phone:918-488-9874
Practice Address - Fax:918-587-3437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22105207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Single Specialty