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General NPI Number Information
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NPI Number | 1427131382
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Entity Type | Organization
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Legal Business Name | LIFESPAN MEDICAL SERVICES LLC
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 06/21/2018
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Provider Practice Location Address
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Address Line | 1125 FORREST AVE
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City | DOVER
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State | DE
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Zip | 19904-3483
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Country | US
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Telephone | 302-346-0100
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Fax | 302-346-0103
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Provider Business Mailing Address
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Address Line | 1125 FORREST AVE
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City | DOVER
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State | DE
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Zip | 19904-3483
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Country | US
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Telephone | 302-346-0100
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Fax | 302-346-0103
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | HARSHA TANKALA
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Credential | M.D.
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Telephone | 302-678-0950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0300X
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Taxonomy Name | Geriatric Medicine (Internal Medicine) Physician
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License Number | C1-0005962
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License Number State | DE
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