Provider Demographics
NPI:1568401883
Name:MID-ATLANTIC LONG TERM CARE OF WESTERN MARYLAND, LLC
Entity Type:Organization
Organization Name:MID-ATLANTIC LONG TERM CARE OF WESTERN MARYLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RIFKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-668-3808
Mailing Address - Street 1:706 E ALDER ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-3554
Mailing Address - Country:US
Mailing Address - Phone:301-334-2319
Mailing Address - Fax:301-334-3345
Practice Address - Street 1:706 E ALDER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-3554
Practice Address - Country:US
Practice Address - Phone:301-334-2319
Practice Address - Fax:301-334-3345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD11001314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC020980900Medicaid
MD407949300Medicaid
MD215232Medicare ID - Type Unspecified