Provider Demographics
NPI:1750795084
Name:LIFEGUARD MEDICAL GROUP,LLC
Entity type:Organization
Organization Name:LIFEGUARD MEDICAL GROUP,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ZACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-696-6863
Mailing Address - Street 1:PO BOX 1356
Mailing Address - Street 2:
Mailing Address - City:OAK BLUFFS
Mailing Address - State:MA
Mailing Address - Zip Code:02557-1356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:72 EASTVILLE AVE
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557
Practice Address - Country:US
Practice Address - Phone:508-696-6863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-14
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213570207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3093018Medicaid
MAH20262Medicare UPIN