Provider Demographics
NPI:1134545841
Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Entity type:Organization
Organization Name:LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT-SISK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-422-9941
Mailing Address - Street 1:913 RIDGEBROOK RD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:913 RIDGEBROOK RD
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:MD
Practice Address - Zip Code:21152-9455
Practice Address - Country:US
Practice Address - Phone:410-601-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-06
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218599Medicare PIN