Basic Information
| Provider Information | |||||||||
| NPI: | 1679525562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | GENESIS MEDICAL CENTER - CVT SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1236 E RUSHOLME ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213990 | ||||||||
| FaxNumber: | 5634213933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1236 E RUSHOLME ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528032433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634213990 | ||||||||
| FaxNumber: | 5634213933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | KLEINSCHMIDT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 5634216513 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 1600338 | 05 | IA | MEDICAID |