Basic Information
| Provider Information | |||||||||
| NPI: | 1801182753 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | GENESIS MEMORY CLINIC, ILLINI CAMPUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | SUITE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559200 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 855 ILLINI DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SILVIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612822907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092812630 | ||||||||
| FaxNumber: | 3092812639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2011 | ||||||||
| LastUpdateDate: | 06/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE / CFO | ||||||||
| AuthorizedOfficialTelephone: | 5634216513 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 2084N0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.