Provider Demographics
NPI:1447456819
Name:LIFEBRIDGE INC
Entity type:Organization
Organization Name:LIFEBRIDGE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-473-2273
Mailing Address - Street 1:374 VIOLET AVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1034
Mailing Address - Country:US
Mailing Address - Phone:845-473-2273
Mailing Address - Fax:845-790-0009
Practice Address - Street 1:45 READE PL
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3947
Practice Address - Country:US
Practice Address - Phone:845-473-2273
Practice Address - Fax:845-790-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02148492Medicaid
NYLI0W312310Medicare ID - Type Unspecified