Basic Information
| Provider Information | |||||||||
| NPI: | 1881636892 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENESIS HEALTH VENTURES OF MASSACHUSETTS, INC. | ||||||||
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| OtherOrganizationName: | HERITAGE HALL SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109254436 | ||||||||
| FaxNumber: | 6109254351 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 COOPER ST | ||||||||
| Address2: | |||||||||
| City: | AGAWAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010012149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137868000 | ||||||||
| FaxNumber: | 4137869788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | DROPESKEY | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CORPORATE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6109254231 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0055 | MA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000000021319 | 01 | BOSTON MEDICAL CENTER | OTHER | 0940224 | 05 | MA | MEDICAID | 71-01265 | 01 | UNITED - EVERCARE | OTHER | 7964490 | 01 | CIGNA(HEALTHSOURCE OF MA) | OTHER | 2222517602 | 01 | MA | BC/BS - VENT | OTHER | 2222517610 | 01 | MA | BC/BS - OUTPATIENT REHAB | OTHER | 2462059 | 01 | AETNA-HMO | OTHER | 0015749 | 01 | NEIGHBORHOOD HEALTH PLAN | OTHER | 2222517601 | 01 | MD | BC/BS | OTHER |