Provider Demographics
NPI:1790321172
Name:LIFEBRIDGE METROPOLITAN PHYSICIAN GROUP II, LLC
Entity Type:Organization
Organization Name:LIFEBRIDGE METROPOLITAN PHYSICIAN GROUP II, LLC
Other - Org Name:VILLAGE PEDIATRICS
Other - Org Type:Doing Business As
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:
Authorized Official - Phone:443-422-9941
Mailing Address - Street 1:535 OLD WESTMINSTER PIKE STE 102
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:MD
Mailing Address - Zip Code:21157-6269
Mailing Address - Country:US
Mailing Address - Phone:410-871-6831
Mailing Address - Fax:410-871-6325
Practice Address - Street 1:1 E UNIVERSITY PKWY UNIT 109
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-2432
Practice Address - Country:US
Practice Address - Phone:410-235-1601
Practice Address - Fax:410-467-6881
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEBRIDGE METROPOLITAN PHYSICIAN GROUP II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-11-21
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty