Provider Demographics
NPI:1568477156
Name:LIFEWAY INC
Entity Type:Organization
Organization Name:LIFEWAY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-772-8554
Mailing Address - Street 1:5333 N DIXIE HWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-3414
Mailing Address - Country:US
Mailing Address - Phone:954-772-8554
Mailing Address - Fax:954-772-9662
Practice Address - Street 1:5333 N DIXIE HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-3414
Practice Address - Country:US
Practice Address - Phone:954-772-8554
Practice Address - Fax:954-772-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6563207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTIN
FL45618Medicare ID - Type Unspecified