Healthcare Provider Details

I. General information

NPI: 1407256985
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2014
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

IV. Provider business mailing address

5401 OLD COURT RD
RANDALLSTOWN MD
21133-5103
US

V. Phone/Fax

Practice location:
  • Phone: 410-521-5973
  • Fax: 410-521-7669
Mailing address:
  • Phone: 410-521-5973
  • Fax: 410-521-7669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateMD

VIII. Authorized Official

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