Provider Demographics
NPI:1821190158
Name:SOUTH BROADWAY HEALTHCARE GROUP, INC.
Entity Type:Organization
Organization Name:SOUTH BROADWAY HEALTHCARE GROUP, INC.
Other - Org Name:AMBERWOOD MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:I
Authorized Official - Last Name:WEISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-292-5706
Mailing Address - Street 1:245-251 SOUTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663
Mailing Address - Country:US
Mailing Address - Phone:330-339-2151
Mailing Address - Fax:330-339-7099
Practice Address - Street 1:245-251 SOUTH BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663
Practice Address - Country:US
Practice Address - Phone:330-339-2151
Practice Address - Fax:330-339-7099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SABER HEALTHCARE HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-05
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6389314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2334012Medicaid
366253Medicare ID - Type Unspecified