Provider Demographics
NPI:1134214356
Name:LIFETIME FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:LIFETIME FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:BELBEN
Authorized Official - Last Name:SHUPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-754-0425
Mailing Address - Street 1:14535 JOHN MARSHALL HWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-4023
Mailing Address - Country:US
Mailing Address - Phone:703-754-0425
Mailing Address - Fax:703-754-2888
Practice Address - Street 1:14535 JOHN MARSHALL HWY
Practice Address - Street 2:SUITE 105
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-4023
Practice Address - Country:US
Practice Address - Phone:703-754-0425
Practice Address - Fax:703-754-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058775207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FO9586Medicare UPIN