Healthcare Provider Details

I. General information

NPI: 1508668377
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY GASTROENTEROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2025
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7704 QUARTERFIELD RD STE A
GLEN BURNIE MD
21061-4412
US

IV. Provider business mailing address

7704 QUARTERFIELD RD STE A
GLEN BURNIE MD
21061-4412
US

V. Phone/Fax

Practice location:
  • Phone: 410-602-7782
  • Fax: 410-602-9344
Mailing address:
  • Phone: 410-602-7782
  • Fax: 410-602-9344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

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