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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician

General Provider Information

NPI Number	:	1477102309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEBRIDGE COMMUNITY PHYSICIANS, INC.

Provider Business Mailing Address
First Line	:	5450 KNOLL NORTH DR STE 100
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2366
Country	:	US
Telephone Number	:	410-601-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	5450 KNOLL NORTH DR STE 100
Second Line	:
City	:	COLUMBIA
State	:	MD
Zip	:	21045-2366
Country	:	US
Telephone Number	:	410-368-1370
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MARY REBECCA WRIGHT-SISK
Credential	:
Telephone Number	:	443-422-9941

Provider Enumeration Date	:	09/04/2019
Last Update Date	:	11/09/2021

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