Basic Information
| Provider Information | |||||||||
| NPI: | 1740222496 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFE MEDICAL, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4201 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529338900 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554164728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529331121 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 02/28/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHEVELEVA | ||||||||
| AuthorizedOfficialFirstName: | OLGA | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCIAL CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 9529331121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.