Provider Demographics
NPI:1831457563
Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Entity Type:Organization
Organization Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Other - Org Name:DRS GOUEL, BLOTNY AND SULLIVAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
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 1:1205 YORK RD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6210
Mailing Address - Country:US
Mailing Address - Phone:410-583-6800
Mailing Address - Fax:410-583-5259
Practice Address - Street 1:1205 YORK RD
Practice Address - Street 2:SUITE 18
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6210
Practice Address - Country:US
Practice Address - Phone:410-583-6800
Practice Address - Fax:410-583-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218599Medicare PIN