Provider Demographics
NPI:1811041668
Name:GOODLIFE MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:GOODLIFE MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLUGBENGA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEBANJO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-685-1994
Mailing Address - Street 1:PO BOX 172126
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-2126
Mailing Address - Country:US
Mailing Address - Phone:901-685-1994
Mailing Address - Fax:901-685-1997
Practice Address - Street 1:756 RIDGE LAKE BLVD
Practice Address - Street 2:SUITE 228
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9420
Practice Address - Country:US
Practice Address - Phone:901-685-1994
Practice Address - Fax:901-685-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37598207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3726671Medicaid
TN3726671Medicare ID - Type Unspecified
TNH98630Medicare UPIN