Healthcare Provider Details

I. General information

NPI: 1629449210
Provider Name (Legal Business Name): LIFESPAN PHYSICIAN GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 METACOM AVE
WARREN RI
02885-2348
US

IV. Provider business mailing address

117 ELLENFIELD ST SUITE 101
PROVIDENCE RI
02905-4513
US

V. Phone/Fax

Practice location:
  • Phone: 401-245-1500
  • Fax: 401-247-2618
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. PETER K MARKELL
Title or Position: EVP & CFO
Credential:
Phone: 401-444-7914