Provider Demographics
NPI:1134234073
Name:LIFELINE FAMILY MEDICINE, P.A.
Entity type:Organization
Organization Name:LIFELINE FAMILY MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:785-434-2622
Mailing Address - Street 1:1210 N. WASHINGTON, CLINIC B
Mailing Address - Street 2:P.O. BOX 407
Mailing Address - City:PLAINVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67663-0407
Mailing Address - Country:US
Mailing Address - Phone:785-434-2622
Mailing Address - Fax:785-434-2577
Practice Address - Street 1:1210 N. WASHINGTON, CLINIC B
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:KS
Practice Address - Zip Code:67663
Practice Address - Country:US
Practice Address - Phone:785-434-2622
Practice Address - Fax:785-434-2577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-30818207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS482220OtherFIRSTGUARD
KS200269400CMedicaid
KS111215OtherBC/BS GROUP
KS105275OtherBC/BS INDIVIDUAL
KS105275Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
KS111215OtherBC/BS GROUP
KS111215Medicare ID - Type UnspecifiedMEDICARE GROUP