Provider Demographics
NPI:1740214758
Name:MEDLIFE INC
Entity Type:Organization
Organization Name:MEDLIFE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:METHENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-268-9882
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-0383
Mailing Address - Country:US
Mailing Address - Phone:812-268-9882
Mailing Address - Fax:812-268-9852
Practice Address - Street 1:12 N STATE ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-1550
Practice Address - Country:US
Practice Address - Phone:812-268-9882
Practice Address - Fax:812-268-9852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06353416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN=========OtherTRICARE HEALTH NET
IN=========OtherTRICARE HEALTH NET