MEDICARE: LIFEBRIDGE MULTI-SPECIALTY, LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1972978625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEBRIDGE MULTI-SPECIALTY, LLC

Provider Business Mailing Address
First Line	:	41 MAGNA WAY
Second Line	:	SUITE 100
City	:	WESTMINSTER
State	:	MD
Zip	:	21157-3073
Country	:	US
Telephone Number	:	410-751-6684
Fax Number	:	410-751-2371

Provider Business Practice Location Address
First Line	:	41 MAGNA WAY
Second Line	:	SUITE 100
City	:	WESTMINSTER
State	:	MD
Zip	:	21157-3073
Country	:	US
Telephone Number	:	410-751-6684
Fax Number	:	410-751-2371

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. MARY R WRIGHT-SISK
Credential	:
Telephone Number	:	410-701-4439

Provider Enumeration Date	:	12/07/2015
Last Update Date	:	12/07/2015

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