Basic Information
| Provider Information | |||||||||
| NPI: | 1437218526 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS MEDICAL GROUP LLC | ||||||||
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| OtherOrganizationName: | CROOKSVILLE FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 945 BETHESDA DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404544788 | ||||||||
| FaxNumber: | 7404506157 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 CHINA STREET | ||||||||
| Address2: | CROOKSVILLE FAMILY CLINIC INC. | ||||||||
| City: | CROOKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437311124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7409826872 | ||||||||
| FaxNumber: | 7409825551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 12/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | MASTERSON | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSIST, TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7404544637 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 207QG0300X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2270313 | 05 | OH | MEDICAID |