Basic Information
| Provider Information | |||||||||
| NPI: | 1164415196 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS ELDERCARE PHYSICIAN SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 62946 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212642946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104947607 | ||||||||
| FaxNumber: | 6109257387 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 EMERSON DR | ||||||||
| Address2: | KIMBERLY HALL NORTH | ||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606886443 | ||||||||
| FaxNumber: | 8606885230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHAPIRO | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, AREA CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4108327790 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004195021 | 05 | CT | MEDICAID | 004126919 | 05 | CT | MEDICAID |