| Organization Name: | LIFEBRIDGE SPORTS MEDICINE & REHABILITATION LLC |
| NPI Number: | 1114215399 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MICHAEL E TARVIN (VICE PRESIDENT & SECRETARY) |
| Mailing Address: | 621 Stemmers Run Rd Suite A Essex |
| State: | MD US |
| Postal Code: | 212213386 |
| Phone Number: | 4106863600 |
| Fax Number: | 4106861056 |
| NPI Enumeration Date: | 07/21/2011 |
| NPI Last Update Date: | 04/28/2016 |
| 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: | |