| Organization Name: | LIFEBRIDGE SPORTS MEDICINE & REHABILITATION LLC |
| NPI Number: | 1003104282 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JAYNE FLECK POOL (CHIEF COMPLIANCE OFFICER) |
| Mailing Address: | 111 Bata Blvd Suite C Belcamp |
| State: | MD US |
| Postal Code: | 210171427 |
| Phone Number: | 4102736000 |
| Fax Number: | 4102736061 |
| NPI Enumeration Date: | 07/21/2011 |
| NPI Last Update Date: | 04/25/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rehabilitation |
| Taxonomy Definition: | |