Basic Information
| Provider Information | |||||||||
| NPI: | 1477576304 | ||||||||
| 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 | ||||||||
| FaxNumber: | 6109257387 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 HAYWOOD AVE | ||||||||
| Address2: | MOUNTAIN VIEW CENTER | ||||||||
| City: | RUTLAND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027750007 | ||||||||
| FaxNumber: | 8027756895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 08/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHAPIRO | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4108327790 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 101-0025776 | VT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 101-0019819 | VT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 207RG0300X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1104819259 | 05 | VT | MEDICAID |