Provider Demographics
NPI:1629495528
Name:LIFEBRIDGE COMMUNITY PEDIATRICS, LLC
Entity Type:Organization
Organization Name:LIFEBRIDGE COMMUNITY PEDIATRICS, LLC
Other - Org Name:MAIN STREET PEDIATRICS
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:410-521-2200
Mailing Address - Street 1:849 FAIRMOUNT AVE STE 100A
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-2600
Mailing Address - Country:US
Mailing Address - Phone:410-494-1369
Mailing Address - Fax:410-494-2737
Practice Address - Street 1:849 FAIRMONT AVENUE
Practice Address - Street 2:SUITE 100A
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-2600
Practice Address - Country:US
Practice Address - Phone:410-494-1369
Practice Address - Fax:410-494-2737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-28
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty