Basic Information
Provider Information | |||||||||
NPI: | 1760864870 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIFEBRIDGE COMMUNITY PHYSICIANS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LIFEBRIDGE HEALTH CARDIOLOGY OF BALTIMORE, LLC D/B/A DR JERALD INSEL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8114 SANDPIPER CIR | ||||||||
Address2: | SUITE 206 | ||||||||
City: | NOTTINGHAM | ||||||||
State: | MD | ||||||||
PostalCode: | 212364934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109334923 | ||||||||
FaxNumber: | 4109338659 | ||||||||
Practice Location | |||||||||
Address1: | 8114 SANDPIPER CIR | ||||||||
Address2: | SUITE 206 | ||||||||
City: | NOTTINGHAM | ||||||||
State: | MD | ||||||||
PostalCode: | 212364934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4109334923 | ||||||||
FaxNumber: | 4109338659 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2015 | ||||||||
LastUpdateDate: | 08/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WRIGHT-SISK | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4434229941 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X |   | MD | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X |   | MD | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.