Provider Demographics
NPI:1245362847
Name:LIFE MEDICAL SC
Entity type:Organization
Organization Name:LIFE MEDICAL SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LESZCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:847-653-8413
Mailing Address - Street 1:1550 N NORTHWEST HWY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1411
Mailing Address - Country:US
Mailing Address - Phone:847-653-8413
Mailing Address - Fax:847-292-0850
Practice Address - Street 1:1550 N NORTHWEST HWY
Practice Address - Street 2:SUITE 209
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1411
Practice Address - Country:US
Practice Address - Phone:847-653-8413
Practice Address - Fax:847-292-0850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042.618530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL042.618530OtherLICENCE