Provider Demographics
NPI:1861689382
Name:LIFEBRIDGE INVESTMENTS, INC
Entity Type:Organization
Organization Name:LIFEBRIDGE INVESTMENTS, INC
Other - Org Name:LIFEBRIDGE COMMUNITY PRACTICES, LLC D/B/A CLINICAL ASSOCIATES ASC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:G
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-296-5300
Mailing Address - Street 1:515 FAIRMOUNT AVE
Mailing Address - Street 2:CREDENTIALING OFFICE
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286
Mailing Address - Country:US
Mailing Address - Phone:410-494-1324
Mailing Address - Fax:410-494-1361
Practice Address - Street 1:515 FAIRMOUNT AVE
Practice Address - Street 2:STE 100A
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5466
Practice Address - Country:US
Practice Address - Phone:410-494-1315
Practice Address - Fax:410-494-1361
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEBRIDGE INVESTMENTS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-28
Last Update Date:2012-08-14
Deactivation Date:2008-02-11
Deactivation Code:
Reactivation Date:2008-04-23
Provider Licenses
StateLicense IDTaxonomies
261QE0800X
MDA261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD417384800Medicaid
MD417384800Medicaid
MDZZ52Medicare PIN