=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912856154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESPAN PHYSICIAN GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2026
-----------------------------------------------------
Last Update Date | 01/23/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195 COLLYER ST STE 104
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02904-1869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-276-2026
-----------------------------------------------------
Fax | 401-276-2025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 LA SALLE SQ
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02903-1814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP REVENUE CYCLE
-----------------------------------------------------
Name | CHRISTINE RAWNSLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-444-6905
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------