NPIMap

Organization Active NPI

Lifebridge Community Pediatrics, LLC

Doing business as Main Street Pediatrics

  • Pediatrics Physician
  • Towson, MD
National Provider Identifier
1629495528
Registry record updated Mar 16, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
LIFEBRIDGE COMMUNITY PEDIATRICS, LLC
Doing business as
Main Street Pediatrics
Practice address
849 Fairmont Avenue
Suite 100a
Towson, MD 21286-2600
Phone
(410) 494-1369
Fax
(410) 494-2737
NPI assigned
Mar 28, 2014
Last updated
Mar 16, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 16, 2020

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
(410) 521-2200

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X MD Primary

Addresses

Primary practice location

849 Fairmont Avenue
Suite 100a
Towson, MD 21286-2600

Mailing address

849 Fairmount Ave Ste 100a
Towson, MD 21286-2600
Phone (410) 494-1369

Other names 1

  • Main Street Pediatrics Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140812000403 MD Part B Supplier - Clinic/Group Practice 6901023167 Receives reassigned benefits from 16 practitioners
Practice locations: Owings Mills, MD; Towson, MD

National Provider Directory

National Provider Directory
Tax ID family
Lifebridge Community Pediatrics LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

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

849 Fairmount Ave
Ste 100A
Towson, MD 21286
Phone (410) 494-1369

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1395964800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1584316800000",
    "number": "1629495528",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "849 FAIRMOUNT AVE STE 100A",
            "city": "TOWSON",
            "state": "MD",
            "postal_code": "212862600",
            "telephone_number": "410-494-1369",
            "fax_number": "410-494-2737"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "849 FAIRMONT AVENUE",
            "address_2": "SUITE 100A",
            "city": "TOWSON",
            "state": "MD",
            "postal_code": "212862600",
            "telephone_number": "410-494-1369",
            "fax_number": "410-494-2737"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFEBRIDGE COMMUNITY PEDIATRICS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-03-28",
        "last_updated": "2020-03-16",
        "certification_date": "2020-03-16",
        "status": "A",
        "authorized_official_last_name": "WRIGHT-SISK",
        "authorized_official_first_name": "MARY",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "410-521-2200"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "MD",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Main Street Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Main Street Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Towson, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 16, 2020; 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.