Provider Demographics
NPI:1407116643
Name:LIFESPAN PHYSICIAN GROUP, INC.
Entity Type:Organization
Organization Name:LIFESPAN PHYSICIAN GROUP, INC.
Other - Org Name:
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
Mailing Address - Street 2:SUITE 101
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 1:593 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-6779
Practice Address - Fax:401-444-6912
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESPAN CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-22
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0028977Medicare Oscar/Certification