Healthcare Provider Details

I. General information

NPI: 1336031392
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY PHYSICIANS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 FAIRMOUNT AVE
TOWSON MD
21286-5466
US

IV. Provider business mailing address

515 FAIRMOUNT AVE
TOWSON MD
21286-5466
US

V. Phone/Fax

Practice location:
  • Phone: 410-469-4000
  • Fax: 410-469-4076
Mailing address:
  • Phone: 410-469-4000
  • Fax: 410-469-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
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: MARY REBECCA WRIGHT-SISK
Title or Position: DIRECTOR
Credential:
Phone: 443-421-9941