MEDICARE: GOODLIFE MEDICAL CENTER, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	37598	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811041668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODLIFE MEDICAL CENTER, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 172126
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38187-2126
Country	:	US
Telephone Number	:	901-685-1994
Fax Number	:	901-685-1997

Provider Business Practice Location Address
First Line	:	756 RIDGE LAKE BLVD
Second Line	:	SUITE 228
City	:	MEMPHIS
State	:	TN
Zip	:	38120-9420
Country	:	US
Telephone Number	:	901-685-1994
Fax Number	:	901-685-1997

Authorized Official
Title or Position	:	PRESIDENT
Name	:	OLUGBENGA ADEBANJO
Credential	:	MD
Telephone Number	:	901-685-1994

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	09/20/2007

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