Provider Demographics
NPI:1861730855
Name:LIFELINE VASCULAR CENTER - ALBANY, LLC
Entity type:Organization
Organization Name:LIFELINE VASCULAR CENTER - ALBANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:LOHMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-949-3855
Mailing Address - Street 1:1 PARKWAY NORTH BLVD STE 200S
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-2534
Mailing Address - Country:US
Mailing Address - Phone:847-388-2001
Mailing Address - Fax:847-388-2020
Practice Address - Street 1:2300 DAWSON RD STE 100
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2804
Practice Address - Country:US
Practice Address - Phone:229-888-6466
Practice Address - Fax:229-888-5464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134472AMedicaid
GA2027012G81Medicare PIN