Provider Demographics
NPI:1972852929
Name:LIFEBRIDGE SPORTS MEDICINE & REHABILITATION LLC
Entity Type:Organization
Organization Name:LIFEBRIDGE SPORTS MEDICINE & REHABILITATION LLC
Other - Org Name:LIFEBRIDGE HEALTH PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT & SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-972-1100
Mailing Address - Street 1:4714 GETTYSBURG RD
Mailing Address - Street 2:LEGAL DEPT
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055-4325
Mailing Address - Country:US
Mailing Address - Phone:717-972-1100
Mailing Address - Fax:
Practice Address - Street 1:10084 REISTERSTOWN RD STE 300B
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4160
Practice Address - Country:US
Practice Address - Phone:443-379-4740
Practice Address - Fax:443-379-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD216566Medicare Oscar/Certification