Provider Demographics
NPI:1982933107
Name:LIFETIME MEDICAL CENTER, PC
Entity Type:Organization
Organization Name:LIFETIME MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-698-5433
Mailing Address - Street 1:14244 HIGHWAY 515 N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30536
Mailing Address - Country:US
Mailing Address - Phone:706-698-5433
Mailing Address - Fax:
Practice Address - Street 1:14244 HIGHWAY 515 N
Practice Address - Street 2:SUITE 100
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30536
Practice Address - Country:US
Practice Address - Phone:706-698-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202 G701 589OtherMEDICARE GROUP #
GAH39633Medicare UPIN