Basic Information
| Provider Information | |||||||||
| NPI: | 1598081739 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 945 BETHESDA DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404544788 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 LINCOLN PARK DR | ||||||||
| Address2: | |||||||||
| City: | NEW LEXINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437641033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403425107 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2010 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | RAYMOND | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7404544788 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENESIS MEDICAL GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.