Healthcare Provider Details

I. General information

NPI: 1811365828
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W BELVEDERE AVE SUITE 102-104
BALTIMORE MD
21215-5216
US

IV. Provider business mailing address

2401 W BELVEDERE AVE SUITE 102-104
BALTIMORE MD
21215-5216
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-8500
  • Fax:
Mailing address:
  • Phone: 410-601-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY R WRIGHT-SISK
Title or Position: DIRECTOR
Credential:
Phone: 443-422-9941