=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740089432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFEBRIDGE COMMUNITY PHYSICIANS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2025
-----------------------------------------------------
Last Update Date | 03/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 CROSSROADS DR STE 100
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-5476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-601-2663
-----------------------------------------------------
Fax | 667-219-6250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 CROSSROADS DR STE 100
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-5476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-601-2663
-----------------------------------------------------
Fax | 667-219-6250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MARY REBECCA WRIGHT-SISK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 434-229-9414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------