Basic Information
| Provider Information | |||||||||
| NPI: | 1063907244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFELINC ANESTHESIA V, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 PLAYERS CLUB PKWY STE 350 | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381258949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018441590 | ||||||||
| FaxNumber: | 8447522163 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723012017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018441590 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | THOMPSON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9012072017 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 232289002 | 05 | AR | MEDICAID |