Basic Information
| Provider Information | |||||||||
| NPI: | 1033535828 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS ELDERCARE PHYSICIAN SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 62946 | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212642946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104947607 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16605 CHESTNUT GLEN PL | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105431957 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2014 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHAPIRO | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4108327790 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENESIS HEALTHCARE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 0858289.09 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.