Provider Demographics
NPI:1700112158
Name:LIFELINE MEDICAL PC
Entity Type:Organization
Organization Name:LIFELINE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-255-2333
Mailing Address - Street 1:121 S OCEAN AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-4558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 S OCEAN AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-4558
Practice Address - Country:US
Practice Address - Phone:212-255-2333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty