Basic Information
| Provider Information | |||||||||
| NPI: | 1821397233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFELINC ANESTHESIA II, PLLC | ||||||||
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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: | 9012072017 | ||||||||
| FaxNumber: | 9018441592 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 NORTHCREST DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018441590 | ||||||||
| FaxNumber: | 9018441592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2011 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | WARREN | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/COO | ||||||||
| AuthorizedOfficialTelephone: | 9012072017 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MHA | ||||||||
| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 7100162450 | 05 | KY | MEDICAID | 7100169260 | 05 | KY | MEDICAID | 1523636 | 05 | TN | MEDICAID |