Basic Information
Provider Information
NPI: 1659492247
EntityType: 2
ReplacementNPI:  
OrganizationName: SSC BALTIMORE OPERATING COMPANY LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: OVERLEA HEALTH AND REHABILITATION CENTER
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5300 W SAM HOUSTON PKWY N
Address2: SUITE 100
City: HOUSTON
State: TX
PostalCode: 770415161
CountryCode: US
TelephoneNumber: 7708295100
FaxNumber:  
Practice Location
Address1: 6116 BELAIR RD
Address2:  
City: BALTIMORE
State: MD
PostalCode: 212061927
CountryCode: US
TelephoneNumber: 4104261424
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/02/2007
LastUpdateDate: 11/11/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SANTORO
AuthorizedOfficialFirstName: KELLE
AuthorizedOfficialMiddleName: C
AuthorizedOfficialTitleorPosition: SR DIRECTOR AR
AuthorizedOfficialTelephone: 8324675728
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 11/11/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
385H00000X30-021MDN Respite Care FacilityRespite Care 
314000000X30-021MDY Nursing & Custodial Care FacilitiesSkilled Nursing Facility 

ID Information
IDTypeStateIssuerDescription
40731690001MDPART B ONLYOTHER
40615350005MD MEDICAID
40615600205MD MEDICAID


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