Provider Demographics
NPI:1194170027
Name:LIFEBRIDGE SUBURBAN PHYSICIAN GROUP II LLC
Entity type:Organization
Organization Name:LIFEBRIDGE SUBURBAN PHYSICIAN GROUP II LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT-SISK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-422-9941
Mailing Address - Street 1:3527 N ROLLING RD
Mailing Address - Street 2:# 1
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2223
Mailing Address - Country:US
Mailing Address - Phone:410-521-7337
Mailing Address - Fax:
Practice Address - Street 1:5400 OLD COURT RD STE 300B
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5100
Practice Address - Country:US
Practice Address - Phone:410-521-7337
Practice Address - Fax:410-521-7377
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEBRIDGE COMMUNITY PHYSICIANS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-28
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218599Medicare PIN