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General NPI Number Information
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NPI Number | 1033900352
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Entity Type | Organization
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Legal Business Name | LIFEBRIDGE SUBURBAN PHYSICIAN GROUP II LLC
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Dates
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Enumeration Date | 05/15/2025
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Last Update Date | 05/15/2025
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Provider Practice Location Address
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Address Line | 1405 MADISON PARK DR
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City | GLEN BURNIE
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State | MD
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Zip | 21061-5627
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Country | US
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Telephone | 410-308-7865
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Fax | 410-308-7818
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Provider Business Mailing Address
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Address Line | 1405 MADISON PARK DR
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City | GLEN BURNIE
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State | MD
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Zip | 21061-5627
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Country | US
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Telephone | 410-308-7865
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Fax | 410-308-7818
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Authorized Official
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Title or Position | DIRECTOR
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Name | MARY REBECCA WRIGHT-SISK
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Credential |
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Telephone | 443-422-9941
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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