Healthcare Provider Details

I. General information

NPI: 1073401972
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4991 NEW DESIGN RD STE 103
FREDERICK MD
21703-7342
US

IV. Provider business mailing address

4991 NEW DESIGN RD STE 103
FREDERICK MD
21703-7342
US

V. Phone/Fax

Practice location:
  • Phone: 443-289-3459
  • Fax: 443-289-3488
Mailing address:
  • Phone: 443-289-3459
  • Fax: 443-289-3488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY REBECCA WRIGHT-SISK
Title or Position: DIRECTOR
Credential:
Phone: 434-229-9414