Basic Information
| Provider Information | |||||||||
| NPI: | 1922043504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PENINSULA REGIONAL-GENESIS ELDERCARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SALISBURY REHABILITATION AND NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254436 | ||||||||
| FaxNumber: | 6109254351 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 CIVIC AVE | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218044599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107491466 | ||||||||
| FaxNumber: | 4107493208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684752 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 22-005 | PA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1039162 | 01 | AETNA-HMO | OTHER | 0004621000 | 01 | AMERIHEALTH | OTHER | 086801900 | 05 | MD | MEDICAID | ML3 | 01 | CAREFIRST - IND/PPO | OTHER | ML3 | 01 | CAREFIRST BLUECHOICE | OTHER | 02B2 | 01 | CAREFIRST PROV/INQ# | OTHER | 185308 | 01 | AMERIGROUP | OTHER | 341382 | 01 | UNITED - MAMSI | OTHER |