Provider Demographics
NPI:1629449210
Name:LIFESPAN PHYSICIAN GROUP, INC.
Entity Type:Organization
Organization Name:LIFESPAN PHYSICIAN GROUP, INC.
Other - Org Name:METACOM MEDICAL
Other - Org Type:Other Name
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 1:639 METACOM AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:RI
Practice Address - Zip Code:02885-2348
Practice Address - Country:US
Practice Address - Phone:401-245-1500
Practice Address - Fax:401-247-2618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty