Basic Information
Provider Information | |||||||||
NPI: | 1851950463 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIFELINC ANESTHESIA NEVADA, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3340 PLAYERS CLUB PKWY STE 350 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381258949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9018441590 | ||||||||
FaxNumber: | 9018441592 | ||||||||
Practice Location | |||||||||
Address1: | 801 E WILLIAMS AVE STE 2209 | ||||||||
Address2: |   | ||||||||
City: | FALLON | ||||||||
State: | NV | ||||||||
PostalCode: | 894063052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9018441590 | ||||||||
FaxNumber: | 9018441592 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2019 | ||||||||
LastUpdateDate: | 09/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMPSON | ||||||||
AuthorizedOfficialFirstName: | GREGORY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9012072017 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
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 | NV |   | MEDICAID |