MEDICARE: LIFEBRIDGE COMMUNITY PHYSICIANS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1053662858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEBRIDGE COMMUNITY PHYSICIANS, INC

Provider Business Mailing Address
First Line	:	12221 TULLAMORE RD # 3
Second Line	:
City	:	LUTHERVILLE TIMONIUM
State	:	MD
Zip	:	21093-7816
Country	:	US
Telephone Number	:	410-494-1884
Fax Number	:	410-308-7841

Provider Business Practice Location Address
First Line	:	12221 TULLAMORE RD # 3
Second Line	:
City	:	LUTHERVILLE TIMONIUM
State	:	MD
Zip	:	21093-7816
Country	:	US
Telephone Number	:	410-494-1884
Fax Number	:	410-308-7841

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. BRIAN CAWLEY
Credential	:
Telephone Number	:	410-521-7572

Provider Enumeration Date	:	09/20/2012
Last Update Date	:	09/20/2012

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Directions to “LIFEBRIDGE COMMUNITY PHYSICIANS, INC ” Practice Location

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