Basic Information
| Provider Information | |||||||||
| NPI: | 1497772008 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GENESIS CONVENIENT CARE BETTENDORF | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 765 | ||||||||
| Address2: | |||||||||
| City: | EAST MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612440765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559200 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 4017 DEVILS GLEN RD | ||||||||
| Address2: | |||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527227221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213700 | ||||||||
| FaxNumber: | 5634213710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 5634216513 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | IA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 2243972 | 05 | IA | MEDICAID | 660022 | 01 | HEALTH ALLIANCE | OTHER | 387175 | 01 | HEALTHLINK | OTHER | IA0100 | 01 | JDHC | OTHER | 08753 | 01 | IA | BLUE CROSS/BLUE SHIELD IA | OTHER | 616351 | 01 | HARVARD PILGRIM | OTHER |