Basic Information
| Provider Information | |||||||||
| NPI: | 1033558416 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFEBRIDGE COMMUNITY GASTROENTEROLOGY, LLC | ||||||||
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| OtherOrganizationName: | WOODHOLME GASTROENTEROLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1838 GREENE TREE RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PIKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212086391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106027782 | ||||||||
| FaxNumber: | 4106029344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1838 GREENE TREE RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PIKESVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212086391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106027782 | ||||||||
| FaxNumber: | 4106029344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2013 | ||||||||
| LastUpdateDate: | 10/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT-SISK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4107014547 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.