NPIMap

Organization Active NPI

Lifebridge Suburban Physician Group II LLC

Doing business as Dr. Jacalyn Blackwell-White

  • Pediatric Adolescent Medicine Physician
  • Randallstown, MD
National Provider Identifier
1194170027
Registry record updated Aug 31, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X
Legal business name
LIFEBRIDGE SUBURBAN PHYSICIAN GROUP II LLC
Doing business as
Dr. Jacalyn Blackwell-White
Practice address
5400 Old Court Rd Ste 300B
Randallstown, MD 21133-5100
Phone
(410) 521-7337
Fax
(410) 521-7377
NPI assigned
Apr 28, 2016
Organization subpart
Yes
Parent organization
LIFEBRIDGE COMMUNITY PHYSICIANS, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 31, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mary Wright-Sisk
Title
Director
Phone
(443) 422-9941

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Adolescent Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2080A0000X Primary

Addresses

Primary practice location

5400 Old Court Rd Ste 300B
Randallstown, MD 21133-5100

Mailing address

3527 N Rolling Rd
# 1
Baltimore, MD 21244-2223
Phone (410) 521-7337

Other practice location 1

3527 N Rolling Rd
# 1
Baltimore, MD 21244-2223
Phone (410) 521-7337

Other names 1

  • Dr. Jacalyn Blackwell-White Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170316002018 MD Part B Supplier - Clinic/Group Practice 3173808045 Receives reassigned benefits from 5 practitioners
2 other NPIs on this enrollment
Practice locations: Lutherville, MD; Baltimore, MD; Glen Burnie, MD

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Dr Gaurav Kumar7 organizations share this tax ID, including this one
Part of
Lifebridge Community Physicians Inc

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

23 Crossroads Dr
Ste 430
Owings Mills, MD 21117

5400 Old Court Rd
Ste 300B
Randallstown, MD 21133
Phone (410) 521-7337

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1461801600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1630368000000",
    "number": "1194170027",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3527 N ROLLING RD",
            "address_2": "# 1",
            "city": "BALTIMORE",
            "state": "MD",
            "postal_code": "212442223",
            "telephone_number": "410-521-7337"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5400 OLD COURT RD STE 300B",
            "city": "RANDALLSTOWN",
            "state": "MD",
            "postal_code": "211335100",
            "telephone_number": "410-521-7337",
            "fax_number": "410-521-7377"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3527 N Rolling Rd",
            "address_2": "# 1",
            "address_purpose": "LOCATION",
            "city": "Baltimore",
            "state": "MD",
            "postal_code": "212442223",
            "country_code": "US",
            "telephone_number": "410-521-7337",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "LIFEBRIDGE SUBURBAN PHYSICIAN GROUP II LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LIFEBRIDGE COMMUNITY PHYSICIANS, INC.",
        "enumeration_date": "2016-04-28",
        "last_updated": "2021-08-31",
        "certification_date": "2021-08-31",
        "status": "A",
        "authorized_official_last_name": "WRIGHT-SISK",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "443-422-9941"
    },
    "taxonomies": [
        {
            "code": "2080A0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dr. Jacalyn Blackwell-White",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Dr. Jacalyn Blackwell-White",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Randallstown, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 31, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.