Healthcare Provider Details

I. General information

NPI: 1851873970
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 FAIRMOUNT AVE STE 100B
TOWSON MD
21286-2600
US

IV. Provider business mailing address

849 FAIRMOUNT AVE STE 100B
TOWSON MD
21286-2600
US

V. Phone/Fax

Practice location:
  • Phone: 410-235-1168
  • Fax: 813-291-7502
Mailing address:
  • Phone: 410-235-1168
  • Fax: 813-291-7502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberD60351
License Number StateMD

VIII. Authorized Official

Name: MS. MARY R WRIGHT-SISK
Title or Position: DIRECTOR
Credential: MD
Phone: 443-422-9941