Basic Information
| Provider Information | |||||||||
| NPI: | 1407801988 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BALTIMORE VA REHAB AND EXTENDED CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 LOCH RAVEN BLVD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212182108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3900 LOCH RAVEN BLVD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212182108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106057000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHAO | ||||||||
| AuthorizedOfficialFirstName: | XIANGRONG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ATTENDING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4106057000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | D56508 | MD | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | M53029 | 01 | MD | CDS | OTHER | BS7766403 | 01 | DEA | OTHER |