MEDICARE: LIFEBRIDGE COMMUNITY PHYSICIANS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician		MD

General Provider Information

NPI Number	:	1609299890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEBRIDGE COMMUNITY PHYSICIANS, INC

Provider Business Mailing Address
First Line	:	8114 HARFORD RD
Second Line	:
City	:	PARKVILLE
State	:	MD
Zip	:	21234-5796
Country	:	US
Telephone Number	:	410-661-5800
Fax Number	:	410-665-4179

Provider Business Practice Location Address
First Line	:	8114 HARFORD RD
Second Line	:
City	:	PARKVILLE
State	:	MD
Zip	:	21234-5796
Country	:	US
Telephone Number	:	410-661-5800
Fax Number	:	410-665-4179

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MARY WRIGHT-SISK
Credential	:
Telephone Number	:	443-422-9941

Provider Enumeration Date	:	01/24/2014
Last Update Date	:	08/27/2021

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