Provider Demographics
NPI:1851835136
Name:LIFEBRIDGE SUBURBAN PHYSICIAN GROUP II, LLC
Entity Type:Organization
Organization Name:LIFEBRIDGE SUBURBAN PHYSICIAN GROUP II, LLC
Other - Org Name:DR. GAURAV KUMAR
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 1:12221 TULLAMORE RD
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-7816
Mailing Address - Country:US
Mailing Address - Phone:410-252-6790
Mailing Address - Fax:
Practice Address - Street 1:12221 TULLAMORE RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-7816
Practice Address - Country:US
Practice Address - Phone:410-252-6790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEBRIDGE COMMUNITY PHYSICIANS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-06
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218599Medicare PIN