=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841237997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYLAND BAPTIST AGED HOME OF THE UNITED BAPTIST MISSIONARY CONVEN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2006
-----------------------------------------------------
Last Update Date | 05/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2801 RAYNER AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21216-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-624-3964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2801 RAYNER AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21216-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-624-3964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. LAVERN JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-945-7650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 30-081
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------