Basic Information
| Provider Information | |||||||||
| NPI: | 1457818338 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFEBRIDGE METROPOLITAN PHYSICIAN GROUP II, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 OLD WESTMINSTER PIKE STE 102 | ||||||||
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| City: | WESTMINSTER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211576269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108716831 | ||||||||
| FaxNumber: | 4108716325 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106019000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2019 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT-SISK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHYSICIAN ENTERPRISE | ||||||||
| AuthorizedOfficialTelephone: | 4434229941 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.