Provider Demographics
NPI:1508225798
Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC.
Entity Type:Organization
Organization Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC.
Other - Org Name:DR. ANISA MIRZA
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 1:849 FAIRMONT AVENUE
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-2600
Mailing Address - Country:US
Mailing Address - Phone:410-469-4981
Mailing Address - Fax:410-469-4983
Practice Address - Street 1:849 FAIRMONT AVENUE
Practice Address - Street 2:SUITE 100B
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-2600
Practice Address - Country:US
Practice Address - Phone:410-469-4981
Practice Address - Fax:410-469-4983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218599Medicare PIN