Healthcare Provider Details

I. General information

NPI: 1790321172
Provider Name (Legal Business Name): LIFEBRIDGE METROPOLITAN PHYSICIAN GROUP II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E UNIVERSITY PKWY UNIT 109
BALTIMORE MD
21218-2432
US

IV. Provider business mailing address

535 OLD WESTMINSTER PIKE STE 102
WESTMINSTER MD
21157-6269
US

V. Phone/Fax

Practice location:
  • Phone: 410-235-1601
  • Fax: 410-467-6881
Mailing address:
  • Phone: 410-871-6831
  • Fax: 410-871-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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