Basic Information
| Provider Information | |||||||||
| NPI: | 1164574604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HCR MANORCARE TOWSON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 E JOPPA RD | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108289494 | ||||||||
| FaxNumber: | 4108289180 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 E JOPPA RD | ||||||||
| Address2: | |||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212865404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108289494 | ||||||||
| FaxNumber: | 4108289180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSING HOME ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4108289494 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 03-022 | MD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 216648 | 01 | MD | KAISER PERMANENTE PROV# | OTHER | PW4 | 01 | MD | BC FEDERAL PROVIDER # | OTHER | C 215054 | 01 | MD | UNITED AMERICAN PROVIDER | OTHER |