Provider Demographics
NPI:1477391274
Name:LIFESMART MEDICAL CENTER PLLC
Entity type:Organization
Organization Name:LIFESMART MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARVATANENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-768-5096
Mailing Address - Street 1:2176 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2405
Mailing Address - Country:US
Mailing Address - Phone:313-768-5096
Mailing Address - Fax:877-409-3290
Practice Address - Street 1:2176 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2405
Practice Address - Country:US
Practice Address - Phone:313-768-5096
Practice Address - Fax:877-409-3290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-16
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty