Provider Demographics
NPI:1285191163
Name:LIFESPAN PHYSICIAN GROUP, INC.
Entity type:Organization
Organization Name:LIFESPAN PHYSICIAN GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP & CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:K
Authorized Official - Last Name:MARKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-444-7914
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4513
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:401-444-6912
Practice Address - Street 1:17 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02889-1001
Practice Address - Country:US
Practice Address - Phone:401-606-2520
Practice Address - Fax:401-384-7190
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESPAN CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-27
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty