Basic Information
| Provider Information | |||||||||
| NPI: | 1407938269 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GENESIS MEDICAL CENTER DEWITT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1118 11TH ST | ||||||||
| Address2: | |||||||||
| City: | DE WITT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527421235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5636594200 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Practice Location | |||||||||
| Address1: | 1118 11TH ST | ||||||||
| Address2: | |||||||||
| City: | DE WITT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527421235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5636594200 | ||||||||
| FaxNumber: | 5634213419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM COF | ||||||||
| AuthorizedOfficialTelephone: | 5634216513 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | IA | N | Hospital Units | Medicare Defined Swing Bed Unit | 282NC0060X | IA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 66062 | 01 | IA | BC OF IOWA SKILLED | OTHER |