Provider Demographics
NPI:1609486778
Name:LIFETIME MEDICAL ASSOCIATES OF AVENTURA
Entity Type:Organization
Organization Name:LIFETIME MEDICAL ASSOCIATES OF AVENTURA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROSKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-409-0197
Mailing Address - Street 1:21097 NE 27TH CT STE 300
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1206
Mailing Address - Country:US
Mailing Address - Phone:786-244-2700
Mailing Address - Fax:800-980-3761
Practice Address - Street 1:21097 NE 27TH CT STE 300
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1206
Practice Address - Country:US
Practice Address - Phone:305-409-0197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-04
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME-74069OtherLICENSE