Basic Information
| Provider Information | |||||||||
| NPI: | 1649415134 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS ELDERCARE PHYSICIAN SERVICES I LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 N SALISBURY BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218013624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105431957 | ||||||||
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| Practice Location | |||||||||
| Address1: | 161 BAKERS RIDGE RD | ||||||||
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| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265081459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042850692 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2008 | ||||||||
| LastUpdateDate: | 12/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | TREGOE | ||||||||
| AuthorizedOfficialFirstName: | CATHERINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BUSINESS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4105438870 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.