Provider Demographics
NPI:1972321461
Name:LIFEBRIDGE COMMUNITY GASTROENTEROLOGY, LLC
Entity type:Organization
Organization Name:LIFEBRIDGE COMMUNITY GASTROENTEROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-871-6831
Mailing Address - Street 1:535 OLD WESTMINSTER PIKE STE 104
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6267
Mailing Address - Country:US
Mailing Address - Phone:410-602-7782
Mailing Address - Fax:410-602-9344
Practice Address - Street 1:535 OLD WESTMINSTER PIKE STE 104
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6267
Practice Address - Country:US
Practice Address - Phone:410-602-7782
Practice Address - Fax:410-602-9344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty