Healthcare Provider Details

I. General information

NPI: 1689477002
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY PULMONOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6334 CEDAR LN
COLUMBIA MD
21044-3898
US

IV. Provider business mailing address

6334 CEDAR LN
COLUMBIA MD
21044-3898
US

V. Phone/Fax

Practice location:
  • Phone: 410-484-5686
  • Fax: 410-484-6472
Mailing address:
  • Phone: 410-484-5686
  • Fax: 410-484-6472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

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