Healthcare Provider Details

I. General information

NPI: 1720085897
Provider Name (Legal Business Name): AUGSBURG LUTHERAN HOME OF MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6811 CAMPFIELD RD
BALTIMORE MD
21207-4657
US

IV. Provider business mailing address

6811 CAMPFIELD RD
BALTIMORE MD
21207-4657
US

V. Phone/Fax

Practice location:
  • Phone: 410-486-4573
  • Fax: 410-653-8744
Mailing address:
  • Phone: 410-486-4573
  • Fax: 410-653-8744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number03-003
License Number StateMD

VIII. Authorized Official

Name: JEROME DAVID POTTER
Title or Position: INFORMATION SYSTEMS MANAGER
Credential:
Phone: 443-471-1004