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General NPI Number Information
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NPI Number | 1225384563
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Entity Type | Organization
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Legal Business Name | LIFELINE HEALTH AND WELLNESS PHYSICIAN SPECIALTY GROUP
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Dates
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Enumeration Date | 07/24/2012
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Last Update Date | 07/24/2012
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Provider Practice Location Address
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Address Line | 1341 N DELAWARE AVE SUITE 307
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City | PHILADELPHIA
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State | PA
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Zip | 19125-4300
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Country | US
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Telephone | 215-922-9334
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Fax | 215-420-1777
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Provider Business Mailing Address
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Address Line | 1341 N DELAWARE AVE SUITE 307
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City | PHILADELPHIA
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State | PA
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Zip | 19125-4300
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Country | US
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Telephone | 215-922-9334
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Fax | 215-420-1777
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Authorized Official
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Title or Position | CEO
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Name | ARTHUR PAUL MIRIANA
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Credential |
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Telephone | 16097036905
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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