NPIMap

Organization Active NPI

Lifesource of North Carolina

Doing business as LifeSource of Georgia

  • General Practice Physician
  • Rome, GA
National Provider Identifier
1962940817
Registry record updated Mar 26, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
Legal business name
LIFESOURCE OF NORTH CAROLINA
Doing business as
LifeSource of Georgia
Practice address
1345 Redmond Cir NW
Rome, GA 30165-1307
Phone
(910) 742-9243
Fax
(888) 746-1787
NPI assigned
Feb 10, 2017
Last updated
Mar 26, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
LIFESOURCE OF NORTH CAROLINAAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 26, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Peggy L Baddour
Title
President
Phone
(910) 777-9165

Specialties & licenses 7

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X
Nurse Practitioner 363L00000X
Psychologist 103T00000X
Clinical Social Worker 1041C0700X
Family Medicine Physician 207Q00000X
Psychiatry Physician 2084P0800X
General Practice Physician 208D00000X Primary

Addresses

Primary practice location

1345 Redmond Cir NW
Rome, GA 30165-1307

Mailing address

PO Box 538622
Atlanta, GA 30353-8622
Phone (910) 535-1211

Other names 1

  • LifeSource of Georgia Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170418000863 GA Part B Supplier - Clinic/Group Practice 7416132428 Receives reassigned benefits from 88 practitioners
Practice locations: Rome, GA

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Part of
Lifesource of Georgia

Practitioners & affiliated clinicians

Practitioners 90

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 90

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1486684800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1616716800000",
    "number": "1962940817",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 538622",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303538622",
            "telephone_number": "910-535-1211"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1345 REDMOND CIR NW",
            "city": "ROME",
            "state": "GA",
            "postal_code": "301651307",
            "telephone_number": "910-742-9243",
            "fax_number": "888-746-1787"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFESOURCE OF NORTH CAROLINA",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LIFESOURCE OF NORTH CAROLINA",
        "enumeration_date": "2017-02-10",
        "last_updated": "2021-03-26",
        "certification_date": "2021-03-26",
        "status": "A",
        "authorized_official_last_name": "BADDOUR",
        "authorized_official_first_name": "PEGGY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "910-777-9165"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LifeSource of Georgia",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "LifeSource of Georgia",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rome, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 26, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.