# LIFEBRIDGE SUBURBAN PHYSICIAN GROUP II LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** LIFEBRIDGE COMMUNITY PHYSICIANS, INC.
- **Other names:** Dr. Jacalyn Blackwell-White
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1194170027
- **Legal business name:** LIFEBRIDGE COMMUNITY PHYSICIANS, INC.
- **Authorized official:** MARY WRIGHT-SISK (DIRECTOR)
- **Authorized official phone:** (443) 422-9941

## Contact information

- **Practice address:** 5400 OLD COURT RD STE 300B, RANDALLSTOWN, MD 21133-5100
- **Practice address phone:** (410) 521-7337
- **Practice address fax:** (410) 521-7377
- **Mailing address:** 3527 N ROLLING RD, \# 1, BALTIMORE, MD 21244-2223
- **Mailing address phone:** (410) 521-7337

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | NULL | Yes |
| 2080A0000X | Pediatric Adolescent Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 04/28/2016
- **Last updated:** 08/31/2021