MEDICARE: THI OF MARYLAND AT LIBERTY HEIGHTS 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	314000000X	Skilled Nursing Facility	30-022	MD

General Provider Information

NPI Number	:	1982641809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THI OF MARYLAND AT LIBERTY HEIGHTS LLC

Provider Business Mailing Address
First Line	:	930 RIDGEBROOK RD
Second Line	:
City	:	SPARKS
State	:	MD
Zip	:	21152-9390
Country	:	US
Telephone Number	:	410-773-1000
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	:	410-542-5306
Fax Number	:

Authorized Official
Title or Position	:	EVP
Name	:	MATTHEW BOX
Credential	:
Telephone Number	:	410-773-1000

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	09/21/2007

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