Provider Demographics
NPI:1902287121
Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Entity Type:Organization
Organization Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Other - Org Name:LIFEBRIDGE HEALTH PRIMARY CARE
Other - Org Type:Doing Business As
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 1:2411 W BELVEDERE AVE
Mailing Address - Street 2:SUITE 504
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5228
Mailing Address - Country:US
Mailing Address - Phone:410-601-0070
Mailing Address - Fax:410-601-0290
Practice Address - Street 1:2411 W BELVEDERE AVE
Practice Address - Street 2:SUITE 504
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5228
Practice Address - Country:US
Practice Address - Phone:410-601-0070
Practice Address - Fax:410-601-0290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2021-08-27
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
MD218599Medicare PIN