Healthcare Provider Details

I. General information

NPI: 1497476451
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2022
Last Update Date: 09/08/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 W BELVEDERE AVE
BALTIMORE MD
21215-5267
US

IV. Provider business mailing address

2434 W BELVEDERE AVE
BALTIMORE MD
21215-5267
US

V. Phone/Fax

Practice location:
  • Phone: 410-601-9355
  • Fax: 410-601-4458
Mailing address:
  • Phone: 410-601-9355
  • Fax: 410-601-4458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY REBECCA WRIGHT-SISK
Title or Position: DIRECTOR
Credential:
Phone: 443-623-8926