1366807885 NPI number — LIFEBRIDGE SUBURBAN PHYSICIANS GROUP, LLC

Table of content: (NPI 1932486685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366807885 NPI number — LIFEBRIDGE SUBURBAN PHYSICIANS GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFEBRIDGE SUBURBAN PHYSICIANS GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366807885
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5401 OLD COURT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANDALLSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21133-5103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-701-4439
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 QUARRY LAKE DR
Provider Second Line Business Practice Location Address:
SUITE 280
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21209-3742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-469-5544
Provider Business Practice Location Address Fax Number:
410-585-2867
Provider Enumeration Date:
12/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT-SISK
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHYSICIAN ENTERPRISE
Authorized Official Telephone Number:
443-422-9941

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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