Healthcare Provider Details

I. General information

NPI: 1093141616
Provider Name (Legal Business Name): LIFEBRIDGE COMMUNITY PHYSICIANS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BALTIMORE BLVD DR ALEXANDER BOGDASCHEWSKYI
WESTMINSTER MD
21157-7055
US

IV. Provider business mailing address

1011 BALTIMORE BLVD DR ALEXANDER BOGDASCHEWSKYI
WESTMINSTER MD
21157-7055
US

V. Phone/Fax

Practice location:
  • Phone: 410-848-8256
  • Fax: 410-848-5950
Mailing address:
  • Phone: 410-848-8256
  • Fax: 410-848-5950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateMD

VIII. Authorized Official

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