Provider Demographics
NPI:1720085897
Name:AUGSBURG LUTHERAN HOME OF MD INC
Entity Type:Organization
Organization Name:AUGSBURG LUTHERAN HOME OF MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INFORMATION SYSTEMS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-471-1004
Mailing Address - Street 1:6811 CAMPFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-4657
Mailing Address - Country:US
Mailing Address - Phone:410-486-4573
Mailing Address - Fax:410-653-8744
Practice Address - Street 1:6811 CAMPFIELD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-4657
Practice Address - Country:US
Practice Address - Phone:410-486-4573
Practice Address - Fax:410-653-8744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03-003314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD71-00455OtherEVERCARE
MD032087100Medicaid
MD21-5193Medicare ID - Type Unspecified