Provider Demographics
NPI:1043217219
Name:SHADY GROVE ADVENTIST NURSING & REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:SHADY GROVE ADVENTIST NURSING & REHABILITATION CENTER INC
Other - Org Name:SHADY GROVE NURSING AND REBAH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, CENTRAL BUSINESS OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARIZAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-315-3272
Mailing Address - Street 1:9701 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3326
Mailing Address - Country:US
Mailing Address - Phone:301-315-1900
Mailing Address - Fax:301-315-1901
Practice Address - Street 1:9701 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3326
Practice Address - Country:US
Practice Address - Phone:301-315-1900
Practice Address - Fax:301-315-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-04
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD158057400Medicaid
MD403480500Medicaid
MD215164Medicare Oscar/Certification