Provider Demographics
NPI:1841237997
Name:MARYLAND BAPTIST AGED HOME OF THE UNITED BAPTIST MISSIONARY CONVEN
Entity Type:Organization
Organization Name:MARYLAND BAPTIST AGED HOME OF THE UNITED BAPTIST MISSIONARY CONVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVERN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-945-7650
Mailing Address - Street 1:2801 RAYNER AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-4628
Mailing Address - Country:US
Mailing Address - Phone:410-624-3964
Mailing Address - Fax:
Practice Address - Street 1:2801 RAYNER AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-4628
Practice Address - Country:US
Practice Address - Phone:410-624-3964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30-081314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD301187900Medicaid