Provider Demographics
NPI:1033558416
Name:LIFEBRIDGE COMMUNITY GASTROENTEROLOGY, LLC
Entity Type:Organization
Organization Name:LIFEBRIDGE COMMUNITY GASTROENTEROLOGY, LLC
Other - Org Name:WOODHOLME GASTROENTEROLOGY ASSOCIATES
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:410-701-4547
Mailing Address - Street 1:1838 GREENE TREE RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6391
Mailing Address - Country:US
Mailing Address - Phone:410-602-7782
Mailing Address - Fax:410-602-9344
Practice Address - Street 1:1838 GREENE TREE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-6391
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:2013-06-19
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty