Provider Demographics
NPI:1790219004
Name:SOUTHERN MARYLAND CENTER FOR INDEPENDENT LIVING
Entity Type:Organization
Organization Name:SOUTHERN MARYLAND CENTER FOR INDEPENDENT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LIDIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELYOVSKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-884-4498
Mailing Address - Street 1:38588 BRETT WAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20659-7218
Mailing Address - Country:US
Mailing Address - Phone:301-884-4498
Mailing Address - Fax:301-884-6099
Practice Address - Street 1:38588 BRETT WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:MECHANICSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20659-7218
Practice Address - Country:US
Practice Address - Phone:301-884-4498
Practice Address - Fax:301-884-6099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD324400800Medicaid