=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639821648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE LINE CORPORATION -4 LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2022
-----------------------------------------------------
Last Update Date | 09/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 349 MALCOLM DR
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21157-6106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-848-2566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1798 ODEN WAY
-----------------------------------------------------
City | ELDERSBURG
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21784-7095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-255-3951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KAMAL G. BANGORIA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 443-255-3951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------