Provider Demographics
NPI:1124433628
Name:LIFEBRIDGE MEDICAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:LIFEBRIDGE MEDICAL ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SULDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-601-5129
Mailing Address - Street 1:4801 DORSEY HALL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7766
Mailing Address - Country:US
Mailing Address - Phone:410-997-5191
Mailing Address - Fax:410-997-7957
Practice Address - Street 1:4801 DORSEY HALL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7766
Practice Address - Country:US
Practice Address - Phone:410-997-5191
Practice Address - Fax:410-997-7957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-24
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD366345Medicare PIN