| Life Line Corporation -4 Llc | |
|
349 Malcolm Dr Westminster MD 21157-6106 | |
| (410) 848-2566 | |
| Not Available |
| Full Name | Life Line Corporation -4 Llc |
|---|---|
| Speciality | Internal Medicine |
| Location | 349 Malcolm Dr, Westminster, Maryland |
| Authorized Official Name and Position | Kamal G. Bangoria (PRESIDENT) |
| Authorized Official Contact | 4432553951 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Life Line Corporation -4 Llc 1798 Oden Way Eldersburg MD 21784-7095 Ph: (443) 255-3951 | Life Line Corporation -4 Llc 349 Malcolm Dr Westminster MD 21157-6106 Ph: (410) 848-2566 |
| NPI Number | 1639821648 |
|---|---|
| Provider Enumeration Date | 01/20/2022 |
| Last Update Date | 01/20/2022 |
| Medicare PECOS PAC ID | 4880061068 |
|---|---|
| Medicare Enrollment ID | O20221031002807 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1639821648 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| 208M00000X | Hospitalist | (* (Not Available)) | Secondary |
| Provider Name | Kamal G Bangoria |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1417168675 PECOS PAC ID: 0143315838 Enrollment ID: I20070926000494 |
| Provider Name | Jillian Dickenski |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1700580438 PECOS PAC ID: 9537525415 Enrollment ID: I20230518002496 |
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