Provider Demographics
NPI:1922441054
Name:LIFE MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:LIFE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADRIANNE
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:RIDLEY-PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-972-7979
Mailing Address - Street 1:14614 LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-3101
Mailing Address - Country:US
Mailing Address - Phone:813-972-7979
Mailing Address - Fax:813-972-2424
Practice Address - Street 1:14614 LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-3101
Practice Address - Country:US
Practice Address - Phone:813-972-7979
Practice Address - Fax:813-972-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2016-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82833208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12523258OtherCAQH