Provider Demographics
NPI:1962756189
Name:LIFEBRIDGE COMMUNITY PHYSICIANS
Entity type:Organization
Organization Name:LIFEBRIDGE COMMUNITY PHYSICIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WRIGHT-SISK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-422-9941
Mailing Address - Street 1:2003 ROCK SPRING RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-2611
Mailing Address - Country:US
Mailing Address - Phone:410-420-0620
Mailing Address - Fax:410-420-0622
Practice Address - Street 1:2003 ROCK SPRING RD
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2611
Practice Address - Country:US
Practice Address - Phone:410-420-0620
Practice Address - Fax:410-420-0622
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-09
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218599Medicare PIN