Healthcare Provider Details

I. General information

NPI: 1770689879
Provider Name (Legal Business Name): LIFEBRIDGE SPORTS MEDICINE & REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12201 TULLAMORE RD
TIMONIUM MD
21093-7816
US

IV. Provider business mailing address

4714 GETTYSBURG RD LEGAL DEPT
MECHANICSBURG PA
17055-4325
US

V. Phone/Fax

Practice location:
  • Phone: 410-308-7850
  • Fax: 410-308-7851
Mailing address:
  • Phone: 717-972-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JOHN F DUGGAN
Title or Position: VICE PRESIDENT
Credential:
Phone: 717-972-1100