MEDICARE: BRIDGEPARK OPERATIONS, LLC

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	385H00000X	Respite Care		MD
2	314000000X	Skilled Nursing Facility		MD

General Provider Information

NPI Number	:	1831696509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEPARK OPERATIONS, LLC

Provider Business Mailing Address
First Line	:	14C 53RD ST STE 220
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11232-2644
Country	:	US
Telephone Number	:	718-567-0400
Fax Number	:

Provider Business Practice Location Address
First Line	:	4017 LIBERTY HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-7545
Country	:	US
Telephone Number	:	877-567-0402
Fax Number	:	718-567-0600

Authorized Official
Title or Position	:	CFO
Name	:	SAM STERN
Credential	:
Telephone Number	:	718-567-0400

Provider Enumeration Date	:	04/10/2018
Last Update Date	:	05/04/2018

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Directions to “BRIDGEPARK OPERATIONS, LLC ” Practice Location

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