Provider Demographics
NPI:1891247003
Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC.
Entity Type:Organization
Organization Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC.
Other - Org Name:BW PRIMARY CARE, LLC
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 1:6190 GEORGETOWN BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6460
Mailing Address - Country:US
Mailing Address - Phone:410-552-5050
Mailing Address - Fax:410-552-0200
Practice Address - Street 1:6190 GEORGETOWN BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6460
Practice Address - Country:US
Practice Address - Phone:410-552-5050
Practice Address - Fax:410-552-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-04
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218599Medicare PIN