Provider Demographics
NPI:1811398175
Name:LIFEBRIDGE PRIMARY CARE OF NORTH CARROLL, LLC
Entity Type:Organization
Organization Name:LIFEBRIDGE PRIMARY CARE OF NORTH CARROLL, LLC
Other - Org Name:CARROLL MEDICAL GROUP
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 1:4231 N WOODS TRL
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:MD
Mailing Address - Zip Code:21074-3128
Mailing Address - Country:US
Mailing Address - Phone:410-374-9391
Mailing Address - Fax:410-374-1866
Practice Address - Street 1:4231 N WOODS TRL
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:MD
Practice Address - Zip Code:21074-3128
Practice Address - Country:US
Practice Address - Phone:410-374-9391
Practice Address - Fax:410-374-1866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-05
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty