Healthcare Provider Details

I. General information

NPI: 1861359531
Provider Name (Legal Business Name): SOUTH RIVER NURSING AND REHAB CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 WASHINGTON RD
EDGEWATER MD
21037-1412
US

IV. Provider business mailing address

144 WASHINGTON RD
EDGEWATER MD
21037-1412
US

V. Phone/Fax

Practice location:
  • Phone: 410-956-5000
  • Fax:
Mailing address:
  • Phone: 410-956-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JACK SHELBY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 917-414-2140