1285191163 NPI number — LIFESPAN PHYSICIAN GROUP, INC.

Table of content: (NPI 1285191163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285191163 NPI number — LIFESPAN PHYSICIAN GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESPAN PHYSICIAN GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285191163
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 ELLENFIELD ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02905-4513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-444-6779
Provider Business Mailing Address Fax Number:
401-444-6912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 AIRPORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARWICK
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02889-1001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-606-2520
Provider Business Practice Location Address Fax Number:
401-384-7190
Provider Enumeration Date:
02/27/2019

Additional Information

Authorized Official

Authorized Official Last Name:
MARKELL
Authorized Official First Name:
PETER
Authorized Official Middle Name:
K
Authorized Official Title or Position:
EVP & CFO
Authorized Official Telephone Number:
401-444-7914

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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