NPIMap

Organization Active NPI

Lifesource Prime Inc

  • Family Medicine Physician
  • Wilmington, NC
National Provider Identifier
1598533275
Registry record updated Oct 28, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
LIFESOURCE PRIME INC
Practice address
3205 Randall Pkwy Ste 105
Wilmington, NC 28403-2565
Phone
(910) 742-9243
Fax
(888) 746-1787
NPI assigned
Dec 13, 2023
Last updated
Oct 28, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 28, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Peggy Baddour
Title
Ceo
Phone
(910) 742-9243

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X Primary

Addresses

Primary practice location

3205 Randall Pkwy Ste 105
Wilmington, NC 28403-2565

Mailing address

PO Box 740343
Atlanta, GA 30374-0343
Phone (910) 338-2882

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240416003922 NC Part B Supplier - Clinic/Group Practice 7810336385 Receives reassigned benefits from 51 practitioners
Practice locations: Clayton, NC; Wilmington, NC

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 63

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 63

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1702425600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1761609600000",
    "number": "1598533275",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 740343",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303740343",
            "telephone_number": "910-338-2882",
            "fax_number": "888-746-1787"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3205 RANDALL PKWY STE 105",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284032565",
            "telephone_number": "910-742-9243",
            "fax_number": "888-746-1787"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFESOURCE PRIME INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-12-13",
        "last_updated": "2025-10-28",
        "certification_date": "2025-10-28",
        "status": "A",
        "authorized_official_last_name": "BADDOUR",
        "authorized_official_first_name": "PEGGY",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "910-742-9243"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Wilmington, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 28, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.