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ObjectId: 201922279349300727 - Submission: 2019-08-15
TIN: 05-0389801
Schedule J
(Form 990)
Department of the Treasury
Internal Revenue Service
Compensation Information
For certain Officers, Directors, Trustees, Key Employees, and Highest
Compensated Employees
Complete if the organization answered "Yes" on Form 990, Part IV, line 23.
Attach to Form 990.
Go to
www.irs.gov/Form990
for instructions and the latest information.
OMB No. 1545-0047
20
17
Open to Public Inspection
Name of the organization
Lifespan Physician Group Inc
Employer identification number
05-0389801
Part I
Questions Regarding Compensation
Yes
No
1a
Check the appropiate box(es) if the organization provided any of the following to or for a person listed on Form
990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items.
First-class or charter travel
Housing allowance or residence for personal use
Travel for companions
Payments for business use of personal residence
Tax idemnification and gross-up payments
Health or social club dues or initiation fees
Discretionary spending account
Personal services (e.g., maid, chauffeur, chef)
b
If any of the boxes in line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain
.........
1b
Yes
2
Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all
directors, trustees, officers, including the CEO/Executive Director, regarding the items checked in line 1a?
..
2
Yes
3
Indicate which, if any, of the following the filing organization used to establish the compensation of the
organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods
used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III.
Compensation committee
Written employment contract
Independent compensation consultant
Compensation survey or study
Form 990 of other organizations
Approval by the board or compensation committee
4
During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization:
a
Receive a severance payment or change-of-control payment?
.............
4a
No
b
Participate in, or receive payment from, a supplemental nonqualified retirement plan?
.........
4b
Yes
c
Participate in, or receive payment from, an equity-based compensation arrangement?
.........
4c
No
If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5-9.
5
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the revenues of:
a
The organization?
....................
5a
No
b
Any related organization?
.......................
5b
No
If "Yes," on line 5a or 5b, describe in Part III.
6
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any
compensation contingent on the net earnings of:
a
The organization?
..................
6a
No
b
Any related organization?
......................
6b
No
If "Yes," on line 6a or 6b, describe in Part III.
7
For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any nonfixed
payments not described in lines 5 and 6? If "Yes," describe in Part III
............
7
Yes
8
Were any amounts reported on Form 990, Part VII, paid or accured pursuant to a contract that was
subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe
in Part III
..........................
8
No
9
If "Yes" on line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)?
.........................
9
No
For Paperwork Reduction Act Notice, see the Instructions for Form 990.
Cat. No. 50053T
Schedule J (Form 990) 2017
Page 2
Schedule J (Form 990) 2017
Page
2
Part II
Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees.
Use duplicate copies if additional space is needed.
For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the
instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII.
Note.
The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(A)
Name and Title
(B)
Breakdown of W-2 and/or 1099-MISC compensation
(C)
Retirement and other deferred compensation
(D)
Nontaxable
benefits
(E)
Total of columns
(B)(i)-(D)
(F)
Compensation in column (B) reported as deferred on prior Form 990
(i)
Base
compensation
(ii)
Bonus & incentive
compensation
(iii)
Other
reportable compensation
1
Adrian D Velasquez MD
Trustee- 11/17
(i)
(ii)
283,299
-------------
31,300
-------------
456
-------------
14,030
-------------
11,635
-------------
340,720
-------------
-------------
2
Anthony L Gallo MD
Physician
(i)
(ii)
274,432
-------------
378,655
-------------
573
-------------
14,779
-------------
26,574
-------------
695,013
-------------
-------------
3
Athena Poppas MD
Trustee
(i)
(ii)
335,844
-------------
149,584
73,479
-------------
3,322
-------------
1,477
10,545
-------------
4,695
14,755
-------------
6,570
437,945
-------------
162,326
-------------
4
Bradley J Collins MD
Trustee
(i)
(ii)
276,390
-------------
30,198
-------------
454
-------------
13,342
-------------
24,881
-------------
345,265
-------------
-------------
5
Chanika Phornphutkul MD
Trustee
(i)
(ii)
193,601
-------------
8,525
-------------
3,668
-------------
9,924
-------------
25,996
-------------
241,714
-------------
-------------
6
Christina A Bandera MD
Trustee- 11/17
(i)
(ii)
385,222
-------------
36,100
-------------
3,113
-------------
15,240
-------------
27,233
-------------
466,908
-------------
-------------
7
Curtis E Doberstein MD
Trustee
(i)
(ii)
-------------
1,120,911
-------------
125,000
-------------
4,002
-------------
15,240
-------------
24,896
-------------
1,290,049
-------------
8
Daniel J Levine MD
Trustee
(i)
(ii)
258,369
-------------
97,668
158,665
-------------
5,180
-------------
2,302
11,060
-------------
4,180
23,803
-------------
8,996
457,077
-------------
113,146
-------------
9
Debra Lobato-Barrera PhD
Trustee
(i)
(ii)
160,668
-------------
-------------
3,976
-------------
10,015
-------------
22,953
-------------
197,612
-------------
-------------
10
Gildasio Oliveira Jr MD
Trustee
(i)
(ii)
586,878
-------------
222,576
-------------
15,038
-------------
13,970
-------------
26,364
-------------
864,826
-------------
-------------
11
Henry T Sachs III MD
Trustee- 11/17
(i)
(ii)
-------------
288,680
-------------
66,336
-------------
40,349
-------------
50,225
-------------
22,454
-------------
468,044
-------------
29,546
12
John B Murphy MD
Secretary
(i)
(ii)
-------------
531,893
-------------
160,000
-------------
115,546
-------------
6,750
-------------
18,230
-------------
832,419
-------------
13
Kristopher R Davignon MD
Trustee- 11/17
(i)
(ii)
454,161
-------------
155,788
-------------
1,046
-------------
15,240
-------------
27,459
-------------
653,694
-------------
-------------
14
Larry A Evans MD
Trustee- 11/17
(i)
(ii)
421,544
-------------
4,186
-------------
4,102
-------------
15,240
-------------
28,553
-------------
473,625
-------------
-------------
15
Lloyd Feit MD
Trustee- 11/17
(i)
(ii)
334,429
-------------
10,981
-------------
4,153
-------------
15,240
-------------
7,015
-------------
371,818
-------------
-------------
16
Margaret A Miller MD
Trustee
(i)
(ii)
318,381
-------------
48,750
-------------
4,097
-------------
15,240
-------------
26,617
-------------
413,085
-------------
-------------
17
Marilyn J Weigner MD
Trustee- 11/17
(i)
(ii)
261,366
-------------
99,069
136,984
-------------
2,486
-------------
1,077
11,050
-------------
4,190
20,768
-------------
7,874
432,654
-------------
112,210
-------------
18
Mary A Wakefield
Treasurer
(i)
(ii)
-------------
684,712
-------------
209,000
-------------
129,199
-------------
264,493
-------------
18,070
-------------
1,305,474
-------------
97,769
19
Meera V Simoes MD
Trustee- 11/17
(i)
(ii)
252,131
-------------
49,160
-------------
502
-------------
12,744
-------------
26,621
-------------
341,158
-------------
-------------
20
Michael E Migliori MD
Trustee
(i)
(ii)
375,046
-------------
11,785
-------------
3,664
-------------
15,240
-------------
24,468
-------------
430,203
-------------
-------------
21
Patricia H Richards
VP of Operations
(i)
(ii)
-------------
232,248
-------------
46,200
-------------
99,854
-------------
8,100
-------------
21,695
-------------
408,097
-------------
22
Paul Y Liu MD
Trustee
(i)
(ii)
656,179
-------------
41,250
-------------
6,536
-------------
15,240
-------------
25,285
-------------
744,490
-------------
-------------
23
Phyllis A Dennery MD
Trustee
(i)
(ii)
539,183
-------------
60,000
-------------
7,482
-------------
15,240
-------------
30,977
-------------
652,882
-------------
-------------
24
Rachel A Sullivan MD
Physician
(i)
(ii)
432,608
-------------
162,500
-------------
778
-------------
15,240
-------------
24,787
-------------
635,913
-------------
-------------
25
Richard G Gillerman MD
Trustee- 11/17
(i)
(ii)
-------------
390,262
-------------
86,576
-------------
50,776
-------------
5,400
-------------
18,938
-------------
551,952
-------------
26
Richard J Goldberg MD
Trustee- 11/17
(i)
(ii)
-------------
436,184
-------------
98,000
-------------
98,858
-------------
16,200
-------------
20,811
-------------
670,053
-------------
27
Rolf H Langeland MD
Physician
(i)
(ii)
510,976
-------------
-------------
57,794
-------------
15,240
-------------
24,845
-------------
608,855
-------------
-------------
28
Steven A Toms MD
Physician
(i)
(ii)
894,876
-------------
-------------
4,003
-------------
15,240
-------------
25,285
-------------
939,404
-------------
-------------
29
Steven Lampert MD
President
(i)
(ii)
474,318
-------------
115,000
-------------
95,221
-------------
5,400
-------------
884
-------------
690,823
-------------
-------------
30
Suzanne E McLaughlin MD
Trustee
(i)
(ii)
170,676
-------------
5,265
-------------
521
-------------
8,024
-------------
23,773
-------------
208,259
-------------
-------------
31
Timothy J Babineau MD
Chair
(i)
(ii)
-------------
1,261,691
-------------
600,490
-------------
355,675
-------------
501,925
-------------
25,892
-------------
2,745,673
-------------
267,558
32
Ziya L Gokaslan MD
Physician
(i)
(ii)
1,344,884
-------------
129,375
-------------
7,483
-------------
15,240
-------------
25,285
-------------
1,522,267
-------------
-------------
Schedule J (Form 990) 2017
Page 3
Schedule J (Form 990) 2017
Page
3
Part III
Supplemental Information
Provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
Return Reference
Explanation
Part I, Line 1a: Relevant information in regards to selections on 1a.
Tax Indemnification and Grossed Up Payments:The Lifespan Executive Long Term Disability program provides financial protection to designated Lifespan physicians and executives in the event that they become disabled. Premiums are paid to the insurance carrier by the insureds on an after-tax basis to allow for income replacement at a reasonable cost. The income associated with the premiums is grossed up to cover the total cost of the benefit as provided in the Lifespan Executive Benefit Plan and is included in Medicare wages, more specifically on Schedule J, Part II, Column B (iii).LPG also purchased professional liability prior acts coverage for certain newly-hired physicians in calendar year 2017. Premiums were paid to insurance carriers by the insureds on an after-tax basis. The income associated with the premiums is grossed-up to cover the total cost of the benefit as provided in the physicians' employment contracts and is included in Medicare wages, more specifically on Schedule J, Part II, Column B (iii).Housing Allowances or Residences for Personal Use:A temporary housing allowance may be provided on a case-by-case basis as part of the recruitment of key executives. The allowance is documented in the individual employment contract or employment offer. In calendar year 2017 LPG provided this benefit to two executives and the taxable amounts paid for the temporary housing resulting from relocation are included in Medicare wages, more specifically on Schedule J, Part II, Column B (iii).
Part I, Line 7: Non-Fixed payments not listed above
Certain physicians and executives participate in incentive compensation plans arranged through individual contractual agreements which stipulate non-fixed payments based on meeting criteria based on various quality and productivity markers.
Schedule J (Form 990) 2017
Additional Data
Software ID:
17005038
Software Version:
2017v2.2