MEDICARE: AUGSBURG LUTHERAN HOME OF MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	03-003	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71-00455	OTHER	MD	EVERCARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720085897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUGSBURG LUTHERAN HOME OF MD INC

Provider Business Mailing Address
First Line	:	6811 CAMPFIELD RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-4657
Country	:	US
Telephone Number	:	410-486-4573
Fax Number	:	410-653-8744

Provider Business Practice Location Address
First Line	:	6811 CAMPFIELD RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-4657
Country	:	US
Telephone Number	:	410-486-4573
Fax Number	:	410-653-8744

Authorized Official
Title or Position	:	INFORMATION SYSTEMS MANAGER
Name	:	JEROME DAVID POTTER
Credential	:
Telephone Number	:	443-471-1004

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	10/24/2011

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