Provider Demographics
NPI:1235517509
Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Entity type:Organization
Organization Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC
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:MD
Authorized Official - Phone:443-422-9941
Mailing Address - Street 1:12221 TULLAMORE RD
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-7816
Mailing Address - Country:US
Mailing Address - Phone:410-601-9355
Mailing Address - Fax:
Practice Address - Street 1:12221 TULLAMORE RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-7816
Practice Address - Country:US
Practice Address - Phone:410-601-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218599Medicare PIN