Provider Demographics
NPI:1922396100
Name:LIFEBRIDGE SPORTS MEDICINE & REHABILITATION LLC
Entity Type:Organization
Organization Name:LIFEBRIDGE SPORTS MEDICINE & REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:FLECK
Authorized Official - Last Name:POOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-884-4803
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-5245
Mailing Address - Country:US
Mailing Address - Phone:724-465-3496
Mailing Address - Fax:215-413-4682
Practice Address - Street 1:9712 BELAIR RD
Practice Address - Street 2:SUITE 101
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-1111
Practice Address - Country:US
Practice Address - Phone:410-256-7070
Practice Address - Fax:410-256-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-21
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216566Medicare Oscar/Certification