Provider Demographics
NPI:1467490003
Name:THI OF MARYLAND AT SOUTH RIVER LLC
Entity Type:Organization
Organization Name:THI OF MARYLAND AT SOUTH RIVER LLC
Other - Org Name:SOUTH RIVER HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-773-1000
Mailing Address - Street 1:930 RIDGEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9390
Mailing Address - Country:US
Mailing Address - Phone:410-773-1000
Mailing Address - Fax:
Practice Address - Street 1:144 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-1412
Practice Address - Country:US
Practice Address - Phone:410-956-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02-013314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
215297Medicare ID - Type Unspecified