Healthcare Provider Details

I. General information

NPI: 1962756189
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2012
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 ROCK SPRING RD
FOREST HILL MD
21050-2611
US

IV. Provider business mailing address

2003 ROCK SPRING RD
FOREST HILL MD
21050-2611
US

V. Phone/Fax

Practice location:
  • Phone: 410-420-0620
  • Fax: 410-420-0622
Mailing address:
  • Phone: 410-420-0620
  • Fax: 410-420-0622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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