Healthcare Provider Details

I. General information

NPI: 1235957713
Provider Name (Legal Business Name): LIFESPAN PHYSICIAN GROUP OF MASSACHUSETTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 POINT ST
PROVIDENCE RI
02903-4771
US

IV. Provider business mailing address

167 POINT ST
PROVIDENCE RI
02903-4771
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4690
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER MARKELL
Title or Position: EVP AND CHIEF FINANCIAL OFFICE
Credential:
Phone: 401-444-7914