Basic Information
Provider Information
NPI: 1629495528
EntityType: 2
ReplacementNPI:  
OrganizationName: LIFEBRIDGE COMMUNITY PEDIATRICS, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
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Credential:  
OtherOrganizationName: MAIN STREET PEDIATRICS
OtherOrganizationType: 3
OtherLastName:  
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Mailing Information
Address1: 849 FAIRMOUNT AVE STE 100A
Address2:  
City: TOWSON
State: MD
PostalCode: 212862600
CountryCode: US
TelephoneNumber: 4104941369
FaxNumber: 4104942737
Practice Location
Address1: 849 FAIRMONT AVENUE
Address2: SUITE 100A
City: TOWSON
State: MD
PostalCode: 212862600
CountryCode: US
TelephoneNumber: 4104941369
FaxNumber: 4104942737
Other Information
ProviderEnumerationDate: 03/28/2014
LastUpdateDate: 03/16/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WRIGHT-SISK
AuthorizedOfficialFirstName: MARY
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: DIRECTOR
AuthorizedOfficialTelephone: 4105212200
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential:  
NPICertificationDate: 03/16/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000X MDY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPediatrics 

No ID Information.


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