Basic Information
| Provider Information | |||||||||
| NPI: | 1306237938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFELINC PAIN MANAGEMENT PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 PLAYERS CLUB PKWY | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381258933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018441590 | ||||||||
| FaxNumber: | 9018441592 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 NORTHCREST DR | ||||||||
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| City: | SPRINGFIELD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371723963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663626963 | ||||||||
| FaxNumber: | 8663624202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2015 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | CALLAN | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER, CEO | ||||||||
| AuthorizedOfficialTelephone: | 9018441590 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 363L00000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367500000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 208VP0000X | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q013363 | 05 | TN | MEDICAID |