Basic Information
| Provider Information | |||||||||
| NPI: | 1871102194 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENESIS MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2951 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405866626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 955 BETHESDA DR | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405866828 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2020 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | NORMAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7404544773 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.